SATA Questions (test 4)

The nurse notes that a patient is positive for the hepatitis B surface antigen. Which questions should the nurse include in the patient’s assessment to help determine the source of the infection?

Select all that apply.

1. “Have you been anywhere where the water may have been contaminated?”
2. “Have you eaten any food in areas where the workers may not have had access to hand washing?”
3. “Have you had unprotected sex with anyone who has hepatitis B?”
4. “Have you eaten any raw shellfish lately?”
5. “Have you had a recent blood transfusion?”
6. “Do you share needles with anyone?”

Show/hide explanation
1) hepatitis A is spread through the fecal-oral route by ingestion of fecal contaminants2) hepatitis A is spread through the fecal-oral route by ingestion of fecal contaminants

3) CORRECT – hepatitis B is shed in the body fluid of infected individuals; a mode of transmission of hepatitis B is from unprotected sex with someone who is infected

4) refers to transmission hepatitis A

5) CORRECT – hepatitis B is shed in the body fluid of infected individuals; a mode of transmission of hepatitis B is from blood transfusions

6) CORRECT – hepatitis B is shed in the body fluid of infected individuals; a mode of transmission of hepatitis B is needle sharing

The nurse provides care for a newly delivered infant with a temperature of 97.2 °F (36.2°C). Which actions will the nurse take when caring for this newborn?

Select all that apply.

1. Place the newborn skin-to-skin on the mother’s chest.
2. Double wrap the newborn in blankets from the clean linen cart.
3. Place a hat/cap on the newborn’s head.
4. Place the dry and diapered newborn under a radiant warmer.
5. Bathe the newborn in warm water while protecting the umbilical stump.

Show/hide explanation
1) CORRECT- Infant needs to be warmed. Skin-to-skin maternal-infant contact can help raise the infant’s temperature.2) Cover the couplet with a warmed blanket. Blankets for newborns with a low temperature need to be pre-warmed; blankets from the linen cart are not pre-warmed.

3) CORRECT – Covering the newborn’s head with a hat/cap, or swaddling in a blanket with its head covered, will help prevent heat loss from the head.

4) CORRECT – Newborns need to wear only a diaper under a radiant warmer; this action increases the surface area to absorb the radiant heat.

5) Newborns need to be thermodynamically stable prior to the first bath. The newborn will lose heat due to evaporation during the bath.

The client was recently admitted from the emergency department. The nurse prepares the client’s prescribed medications. Which steps does the nurse take to ensure the client receives the correct medication?

Select all that apply.

1. Asks another nurse to verify the medications after retrieving the medications from the medication system.
2. Documents the administration of the medications before delivering them to the client.
3. Calls the client by name only to make sure the correct client is receiving the correct medication.
4. Focuses only on the delivery of the medication for the client.
5. Questions the prescriber of a medication if the dose seems too large.
6. Verifies the medication label with the medication administration record three times.

Show/hide explanation
1) double verification is only required for specific medications, such as insulin; double-verifying all medications is impractical; some calculated dosages should be double-checked2) documentation of medication administration is completed immediately after the delivery, not before

3) use at least two client identifiers when administering medications

4) CORRECT — prepare medications for only one client at a time in an uninterrupted environment

5) CORRECT — medication needs to be verified if the dose seems too large or too small

6) CORRECT — labels need to be read at least 3 times and verified with the medication record

The nurse administers medication. While documenting the administration, the nurse realizes an error in administration. Which actions must the nurse take?

Select all that apply.

1. Evaluate the effect of the medication.
2. Notify the patient’s health care provider.
3. Call the hospital’s Risk Manager.
4. Notify the patient of the error.
5. Notify the nurse’s attorney.
6. Complete an occurrence report.

Show/hide explanation
1) CORRECT – One of the nurse’s role is evaluation of therapeutic modalities, even if the patient receives an incorrect treatment.2) CORRECT – The nurse needs to notify the health care provider, the patient, and the charge nurse/nurse manager all need to be informed of the error.

3) Risk Management will be informed via the occurrence/incident report. The department does not need to be informed separately. If the error is significant, e.g. resulted in a death, then the nurse manager will need to contact the Risk Manager.

4) CORRECT – Appropriate action.

5) An attorney needs to be involved only if the patient is harmed. There is no information indicating harm, and harm is not automatically assumed in the event of an erroneous medication administration.

6) CORRECT – The nurse needs to complete an occurrence/incident report .

The nurse prepares a dose of enoxaparin (Lovenox) for the patient after a hip replacement. Which supplies will the nurse need to best deliver the prescribed medication from a multi-dose vial?

Select all that apply.

1. A 3 mL syringe.
2. A 28 gauge needle.
3. A medication cup.
4. Alcohol swabs.
5. A medication label.

Show/hide explanation
1) Lovenox is only administered subcutaneously (SQ). A routine dose of Lovenox is less than 1 mL and is most safely administered from a 1 mL syringe.2) CORRECT – A smaller gauge needle is appropriate because the medication is delivered subcutaneously.

3) A medication cup is not necessary because the medication is delivered SQ.

4) CORRECT – Alcohol swabs are needed to prepare the skin prior to administration.

5) CORRECT – For safety reasons, the medication must be labeled after it is drawn.

An 88-year-old client has two units of packed blood cells ordered for transfusion. The client does not have an IV. Which supplies does the nurse gather when preparing to administer the blood?

Select all that apply.

1. Secondary solution of 5% dextrose solution.
2. Filtered piggyback tubing.
3. 20 gauge IV cannula.
4. Blood pressure cuff.
5. Thermometer.
6. Glucometer.

Show/hide explanation
1) when administering blood, the secondary solution is normal saline, which reduces the risk of hemolysis of the red cells2) CORRECT — blood is administered with a 20-micron in-line filter

3) CORRECT — age consideration for this client is the administration of blood through a smaller-bore cannula (20 or 22 gauge); nursing care will require a slower administration of the blood

4) CORRECT — frequent vital signs are required when administering blood

5) CORRECT — obtain temperature to assess for reactions

6) glucometer is not necessary when administering blood; blood glucose levels are not affected by blood administration

The nurse prepares 0900 medications for a 90-year-old client who was recently transferred from an assisted care facility. The nurse will use which actions to identify the client to ensure the correct client receives the medication?

Select all that apply.

1. Ask the client to state the client’s name.
2. Ask the roommate to identify the client.
3. Check the name on the client’s identification band.
4. Compare the client to a photo of the client in the chart.
5. Check the client’s room number against the admission record.
6. Scan the bar code on the client’s ID bracelet.

Show/hide explanation
1) CORRECT— Two client identifiers must be determined before administering any medication. Calling the client by name is an acceptable identifier.2) Two client identifiers must be determined before administering any medication. Asking the roommate to identify the client is not appropriate.

3) CORRECT— Two client identifiers must be determined before administering any medication. Checking the name on the client’s identification band is an appropriate action.

4) CORRECT— Two client identifiers must be determined before administering any medication. Comparing the client to a photo is an appropriate identifier. Clients transferred from a residential facility frequently have photos in their client records because identification bands are not often worn in these types of facilities.

5) The client could have been moved to a different room since admission.

6) CORRECT— Two client identifiers must be determined before administering any medication. Using a bar code system is an appropriate action.

The patient is admitted to the ambulatory care unit for cataract removal and lens replacement. The nurse marks the patient’s left eye after verifying the consent with the patient. During the immediate pre-operative period, the nurse calls for a “time out.” Which actions will be included in the “time out”?

Select all that apply.

1. The surgeon will indicate the left eye is the operative eye.
2. The anesthesiologist will verify the consent has been signed.
3. The scrub nurse will only use instruments indicated for the left eye.
4. The patient will indicate cataract removal of the left eye.
5. The circulating nurse will identify the patient by name and date of birth.
6. The circulating nurse and the surgeon will agree that the left eye is the operative eye.

Show/hide explanation
1) CORRECT— A “time out” is called before the initiation of any surgical procedure. Cataract surgery is conducted with a local anesthetic and sedation. Before sedation, the patient can be involved in the “time out” procedure. The goals of the “time out” are to correctly identify the patient, correctly identify the operative site and side, and verify that the OR team is in agreement on the procedure to be performed.2) Verification of the consent is performed before arrival in the OR.

3) Instruments are not identified as right- and left-sided.

4) CORRECT— Part of the time out procedure.

5) CORRECT— Part of the time out procedure.

6) CORRECT—The goals of the “time out” are to correctly identify the patient, correctly identify the operative site and side, and verify that the OR team is in agreement on the procedure to be performed.

The nurse manager of the newborn nursery notes an increase in the number of newborns readmitted to the hospital. The infants are diagnosed with infections acquired during their initial stays in the newborn nursery. The nurse manager decides to review medical asepsis with the nursery staff. Which actions should be included in the review?

Select all that apply.

1. Use of betadine on the prepuce of the penis before circumcision.
2. Three-minute hand scrub before entering the nursery.
3. Consistent use of hand sanitizer between caring for different newborns.
4. Use of sterile gloves when providing newborn care before the newborn’s bath.
5. Changing the linen in the crib once a day.

Show/hide explanation
1) Medical asepsis is known as clean technique; uses techniques that inhibit growth and spread of pathogens. Using betadine prior to circumcision applies the principles of surgical asepsis.2) CORRECT— A 3-minute scrub is particular to the newborn nursery area and included in medical asepsis.

3) CORRECT— Hand hygiene is included in medical asepsis.

4) Non-sterile gloves are used.

5) CORRECT— Changing linen is included in medical asepsis.

The facility-wide nursing management team is concerned about the rise in the number of hospital acquired infections identified during the past year. The team decides to review the hospital policies that include sterile technique. Which policies will the team review?

Select all that apply.

1. Preparation of fresh fruits and vegetables for consumption.
2. Foley catheter insertion.
3. Flash (quick) instrument sterilization.
4. Hand washing.
5. Operative site preparation.
6. Placement of a central venous catheter.

Show/hide explanation
1) Sterile technique includes the process and procedures that destroy all microorganisms. Food preparation is considered a clean technique and requires the preparers to wash their hands before food preparation.2) CORRECT— Catheter insertion for clients in the hospital require sterile technique.

3) CORRECT— Sterile technique includes the process and procedures that destroy all microorganisms.

4) Hand washing applies the principles of medical asepsis and therefore is a clean technique.

5) CORRECT—Operative site preparation requires sterile technique.

6) CORRECT — Inserting a central venous catheter requires sterile technique.

The nurse provides care to an 87-year-old client who was just transferred from a long-term residential care facility. Recently, the client became agitated and increasingly confused. The initial nursing assessment reveals a foul smelling discharge in the perineal area. Which nursing actions are necessary upon the patient’s admission to an acute care facility?

Select all that apply.

1. Place an indwelling Foley catheter.
2. Contact the healthcare provider.
3. Take pictures of the affected area.
4. Scrub the perineal area with a bacteriostatic solution.
5. Document the condition of the perineal area.

Show/hide explanation
1) Indwelling catheters increase the risk for infection.2) CORRECT— The healthcare provider needs to be informed. Cultures need to be ordered so the non-hospital acquired infection may be documented and treated accordingly. An infection is the likely cause for the agitation and confusion.

3) Pictures of the peri area are not included in the standard of care.

4) A bacteriostatic solution kills the microorganisms before an appropriate treatment plan can be determined.

5) CORRECT—Appropriate action.

The charge nurse reviews a list of patients admitted to an inpatient acute care unit. During the hand-off report, the nurse plans to alert the staff to the patients who are at highest risk for developing methicillin-resistant Staphylococcus aureus (MRSA). Which patients will the nurse include in the alert?

Select all that apply.

1. The patient who has had an indwelling Foley catheter in place for 48 hours.
2. The patient who is receiving vincristine (Oncovin) through an indwelling port.
3. The patient admitted with elevated troponin levels.
4. The patient with a CD4 (T-cell) count of 200.
5. The patient who is recovering from a closed fractured femur.
6. The patient with a temperature of 100° F (37.7° C).

Show/hide explanation
1) CORRECT— MRSA is spread by direct contact and invades patients who have an existing portal of entry, such as a Foley catheter, a vascular access devise, and an endotracheal tube.2) CORRECT— MRSA is spread by direct contact and invades patients who have an existing portal of entry, such as a Foley catheter, a vascular access devise, and an endotracheal tube.

3) The patient with the elevated troponin level has had a myocardial infarction and has no additional risk for MRSA.

4) CORRECT— Immunocompromised people are at risk for MRSA. T-cell counts are generally between 500-1000; if below 400, the patient is immunocompromised.

5) There is no additional information about the patient with the fractured femur to indicate additional risk of MRSA.

6) There is no additional information about the patient with the fever to indicate additional risk of MRSA.

A 78-year-old patient is transferred within an acute care facility to long-term care with the diagnosis of a stroke. The patient has become increasingly confused over the past 2 days. Multiple laboratory tests are prescribed. Which findings would cause the nurse to contact the healthcare provider?

Select all that apply.

1. Heart rate of 86 beats per minute.
2. Blood glucose level of 96 mg/dL.
3. Urinalysis positive for nitrites.
4. Potassium of 3.8 mEq/L.
5. Temperature of 101.3⁰ F (38.5⁰ C).
6. White blood cell count of 18,000/mm3.

Show/hide explanation
1) The heart rate, blood glucose, and potassium levels are within normal limits.2) The heart rate, blood glucose, and potassium levels are within normal limits.

3) CORRECT— Positive nitrite in the urine is an indication of a urinary tract infection.

4) The heart rate, blood glucose, and potassium levels are within normal limits.

5) CORRECT— Confusion in an elderly patient is common when the patient has a urinary tract infection. Elevated temperature and WBC are indications of an infection.

6) CORRECT— Elevated temperature and WBC are indications of an infection. This patient has a urinary tract infection that needs to be treated before urosepsis develops. Promptly reporting outstanding values is the registered nurse’s responsibility.

The nurse prepares the oral medications for the client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA). Which personal protective equipment (PPE) does the nurse put on before entering the client’s room?

Select all that apply.

1. Gown.
2. Gloves.
3. Mask.
4. Eyewear.
5. Foot covers.
6. Hair cover.

Show/hide explanation
1) CORRECT — MRSA is spread by direct contact and requires contact precautions; wear gown when entering room if clothing will have contact with client or environmental surfaces or if client is incontinent, has diarrhea, has an ileostomy, a colostomy, or wound drainage; remove PPE before leaving room2) CORRECT — nurse should wear clean, nonsterile gloves for client contact or contact with potentially contaminated areas; remove PPE before leaving room

3) wearing mask is part of standard precautions; wear mask, eye protection, face shield if there is danger of splashes or sprays of blood, bodily fluids, or excretions; does not apply when administering oral medication

4) wearing eyewear is part of standard precautions; wear mask, eye protection, face shield if there is danger of splashes or sprays of blood, bodily fluids, or excretions; does not apply when administering oral medication

5) foot covers not required

6) hair cover not required

The client recently diagnosed with chronic obstructive pulmonary disease (COPD) prepares for discharge. The nurse coordinates the client’s discharge with the case manager. Which items will the nurse request so the client’s home care needs are met?

Select all that apply.

1. An apnea alarm.
2. An incentive spirometer (IS).
3. Oxygen therapy.
4. Nebulizer equipment.
5. A medical alert bracelet.
6. A smoke alarm.

Show/hide explanation
1) Apnea is not a problem with COPD. Therefore, an alarm is not necessary.2) An incentive spirometer is used to increase inspiratory lung volume. COPD is a restrictive disease. Incentive spirometry is sustanined maximal inspiration used postoperatively to prevent or treat atelectasis.

3) CORRECT— Oxygen therapy necessary for the client to help improve oxygenation.

4) CORRECT— Nebulizer necessary for the client to help improve oxygenation.

5) CORRECT— A medical alert bracelet is necessary for notification of the patient’s condition.

6) Home care nurse should assess for presence of smoke alarm. This is not the responsibility of the staff nurse.

The nurse instructs the parents of a child recently diagnosed with cystic fibrosis (CF) about how to perform percussion and postural drainage. The nurse determines teaching is appropriate if the parents state which of the following?

Select all that apply.

1. “I shall position my child in a side lying position with the right side of the chest elevated on pillows.”
2. “I shall place my child in a prone with thorax and abdomen elevated.”
3. “I shall place my child supine with head elevated 20 degrees.”
4. “I shall place my child in a knee-chest position and place pillows under the chest.”
5. “I shall place my child in an upright position.”

Show/hide explanation
1) CORRECT— The goal of postural drainage is to facilitate the movement of the thick secretions from the lungs that are prevalent in cystic fibrosis. Head is in dependent position which facilitates the movement of secretions.2) CORRECT — Head in dependent position which facilitates the movement of secretions.

3) Head not in dependent position.

4) CORRECT— Head in dependent position which will facilitate the movement of secretions from the lungs.

5) Client sitting upright, head not in dependent position.

The emergency department nurse admits the client reporting a severe headache. The nurse notes right-sided weakness and the client is hypertensive. Which nursing actions must the nurse implement in the first hour of care?

Select all that apply.

1. Offer the client a semi-soft diet.
2. Contact physical therapy for consultation.
3. Draw labs for complete blood count, including platelets.
4. Complete the order for a computed tomography (CT) scan.
5. Teach the patient about what to expect during a lumbar puncture.
6. Initiate an IV of LR at 50 mL/hour.

Show/hide explanation
1) Client admitted with indicates of a stroke. The patient will remain NPO until the diagnostic studies are complete.2) Physical therapy may be involved because the patient has right-sided weakness. However, the consultation will not occur within the first hour because the patient is not yet stable.

3) CORRECT — A complete blood count will be ordered to evaluate for any internal hemorrhaging and use of clotting factors during the initial phase of a stroke.

4) CORRECT — A CT scan can detect for differences between and ischemic and hemorrhagic stroke, as well as the size and location of the stroke.

5) CORRECT— A lumbar puncture may be ordered for detection of blood in the cerebral spinal fluid.

6) CORRECT— An IV is necessary at a slow rate so medications can be delivered intravenously if needed. Fluid overload needs to be avoided in patients diagnosed with stroke, so the rate of fluid infusion will be very low at first.

The patient presents to the emergency department reporting chest pain and heaviness in the chest. Which of the following will the nurse include in the patient’s focused assessment for reports of chest pain?

Select all that apply.

1. Overall skin tone and color.
2. Subcutaneous emphysema.
3. Neck vein distention.
4. Edema to the lower extremities.
5. Capillary refill to the fingers and toes.
6. Aphasia.

Show/hide explanation
1) CORRECT— Skin tone and color indicates overall circulatory patterns.2) Subcutaneous emphysema occurs with the rupture of alveoli and is seen with or before the development of a pneumothorax. The patient would display severe shortness of breath with a pneumothorax.

3) CORRECT— Right-sided heart failure can cause neck vein distention when the patient changes from a supine to upright position.

4) CORRECT— Edema to the lower extremities is a sign of right-sided failure.

5) CORRECT— Peripheral perfusion is assessed with capillary refill.

6) Aphasia is the loss of the ability to speak and is not associated with chest pain.

The emergency department nurse reviews discharge instructions for the client diagnosed with angina. The nurse instructs the client about the difference between chest pain caused by angina and myocardial infarction. The nurse determines teaching is effective if the client makes which statement?

Select all that apply.

1. “Pain caused by angina causes an intense stabbing pain.”
2. “Exertion may cause angina pain.”
3. “Pain caused by angina is relieved by sitting upright.”
4. “Pain caused by angina often occurs early in the morning.”
5. “Anginal pain is relieved with the administration of nitroglycerine (NTG).”

Show/hide explanation
1) Angina pain is characterized as a squeezing or viselike pain. Intense stabbing pain is more closely associated with a myocardial infarction (MI).2) CORRECT— Exertion, emotion, and/or extremes in temperature are precipitating factors in angina pain.

3) Pericarditis is often relived by sitting upright, whereas angina pain is relieved with rest.

4) MI pain more closely correlates with the morning hours.

5) CORRECT— NTG often relieves angina pain.

The nurse plans to teach about the benefits of probiotic therapy to the members of a local garden club. The nurse states that people diagnosed with which disorders benefit most from probiotic therapy?

Select all that apply.

1. Antibiotic-associated diarrhea.
2. Coronary artery disease.
3. Transient ischemic attacks.
4. Irritable bowel syndrome.
5. Lactose intolerance.
6. Asthma.

Show/hide explanation
1) CORRECT— Probiotics are live microorganisms similar to those found in the gastrointestinal (GI) track. When colonized, they enhance the immune response and stabilize the mucosal barrier in the digestive track.2) Clients diagnosed with cardiac disorders do not benefit from probiotic therapy.

3) Clients diagnosed with vascular disorders do not benefit from probiotic therapy.

4) CORRECT— Irritable bowel syndrome manifested by changes in intestinal motility. Indications are alterations in bowel pattern, pain, bloating, and abdominal distention. Client may benefit from probiotic therapy.

5) CORRECT— Lactose intolerance is a condition of malabsorption due to deficiency of intestinal lactase. Client may benefit from probiotic therapy.

6) Clients diagnosed with respiratory disorders do not benefit from probiotic therapy.

The nurse plans a healthy-living session for a group of seniors at an independent living center. Which advice, founded on evidence-based practice, does the nurse include in the teaching session?

Select all that apply.

1. Include at least five servings of fruits and vegetables and six servings of whole grains.
2. Socialize only with people living in the independent living center.
3. Sit outside in the sun for 10-15 minutes two to three times per week to facilitate production of vitamin D.
4. Get a tetanus booster and a pneumonia immunization shot every 5 years.
5. Decrease calcium intake to 500 mg daily.

Show/hide explanation
1) CORRECT — complex carbohydrates and fiber are needed for a healthy digestive system2) isolation is a problem among the elderly, and they need to be encouraged to socialize in healthy and safe environments, such as a local senior center; clients should not socialize exclusively with one group

3) CORRECT — vitamin D is necessary for calcium absorption; the easiest way to facilitate production of vitamin D is through limited exposure to the sun

4) the tetanus booster is needed every 10 years; an influenza vaccination is needed annually; the pneumococcal vaccination is administered to high-risk groups younger than 65 years and to others at 65 years and every 5 years thereafter

5) calcium intake should be 1000-1500 mg daily

The nurse cares for the client reporting generalized fatigue despite getting 7 to 8 hours of sleep a night. The client’s lab values are as follows: albumin 4.2 g/dL, sodium 142 mEq/L, hematocrit is 31%, and hemoglobin is 9.6 g/dL. Based on these lab values, the nurse should encourage the client to increase intake of which foods?

Select all that apply.

1. Chicken breast.
2. Instant oatmeal.
3. Steamed clams.
4. Steamed green beans.
5. Corn on the cob.
6. Tuna.

Show/hide explanation
1) Client has indications of anemia which is decrease in red cells or hemoglobin content or altered hemoglobin function; caused by decreased red cell production, blood loss, or increased destruction of red cells. Tissue hypoxia causes fatigue, pallor of the skin and mucous membranes, increased respiratory rate and depth, dizziness, difficulty concentrating, cold intolerance. Organ meats are high in iron. Should encourage chicken giblets rather than the chicken breast.2) CORRECT— Fortified cereals good source of iron.

3) CORRECT— Oysters, clams, and scallops (mollusks) are a top-ten source of iron.

4) Dark, leafy vegetables such as spinach and collards are good sources of iron.

5) Corn-on-the-cob is a carbohydrate food and not a good source of iron.

6) Mollusks, red meat, egg yolks, and poultry giblets are good sources of iron.

The clinic nurse instructs the client schedule for a hip replacement about the necessary devices needed at home after the procedure. The nurse determines teaching is successful if the client makes which statements?

Select all that apply.

1. “I will use an elevated toilet seat.”
2. “I will borrow a wheel chair from my neighbor.”
3. “I will have a hand brake installed on my car.”
4. “I will use a shower chair and a hand-held shower.”
5. “I have practiced using a grabber.”
6. “I will obtain a glucometer.”

Show/hide explanation
1) CORRECT— After a hip replacement, it is important that the client prevent hip flexion and promote stability. Using an elevated toilet seat prevents hip flexion2) Client may require a walker, but under usual circumstances a wheelchair is not necessary.

3) By the time the postoperative client can drive a car, a hand brake is not be necessary.

4) CORRECT— Provides for safety and stability. Instruct client to avoiding bending to prevent hip flexion.

5) CORRECT— Using a grabber prevents the client from flexing the hip while picking up items in low areas or having to climb to reach items over the head.

6) No relationship between glucometer and hip replacement.

The nurse cares for geriatric clients. Which actions does the nurse take to reduce the possibility of hip fracture within the geriatric population?

Select all that apply.

1. Instructs the clients to eat four servings of dairy products each day.
2. Asks the clients about exposure to the sun.
3. Determines the type of flooring in the clients’ home.
4. Instructs the clients how to use a walker when ambulating.
5. Contacts an occupational therapist to have a ramp installed at home.
6. Reviews leg-strengthening exercises.

Show/hide explanation
1) CORRECT — adequate sources of calcium and vitamin D are necessary to support bone strength2) CORRECT — fifteen to twenty minutes of exposure to the sun three to four times per week facilitates vitamin D necessary for calcium absorption

3) CORRECT — slick waxed floors and scatter rugs are trip hazards

4) there is no indication in the question that any of the clients are in need of a walker, as many elderly people are ambulatory without assistance

5) there is no indication in the question that any of the clients are in need of a ramp, as many elderly people are ambulatory without assistance

6) CORRECT — leg-strengthening exercises can promote muscle growth and improve coordination, therefore decreasing the risk of hip fracture

The client at 39 weeks gestation is in active labor assisted by oxytocin (Pitocin). The nurse notes the development of late decelerations on the fetal monitor strip. Which actions must the nurse take in the next 60 seconds?

Select all that apply.

1. Reduce the infusion of pitocin from 10 mL/h to 6 mL/h.
2. Position the client on her left side.
3. Increase the IV infusion of Lactated Ringers.
4. Notify the client’s support person.
5. Apply a re-breather mask with oxygen flowing at 10 L/minute.
6. Call the scrub tech and set up the operating room for a cesarean section.

Show/hide explanation
1) Late deceleration are caused by uteroplacental insufficiency, cord compression, and/or maternal supine hypotensive syndrome; fetal hypoxia and acidosis usually result. The goal of the nursing actions is to increase oxygenation to the fetus. The infusion of Pitocin must be turned off to decrease the frequency of contractions.2) CORRECT— Positioning the client on her left side decreases the weight of the uterus on the vena cava and increases oxygen flow to the placenta.

3) CORRECT— Increasing the infusion of LR is called a fluid resuscitation and decreases the viscosity of the blood. The end effect is increasing oxygenation.

4) The support person needs to understand what is happening, but this is not a priority in the first minute.

5) CORRECT— Applying a re-breather mask will increase oxygenation.

6) There is no immediate indication for a cesarean section.

The nurse assists in the delivery and receives a newborn infant. Which are the nurse’s priority actions in the first 10 minutes of the newborn’s life?

Select all that apply.

1. Assign the Apgar scores.
2. Take all vital signs except blood pressure.
3. Administer the Hepatitis B injection.
4. Place a cap/hat on the newborn’s head.
5. Place identification band on the mother and infant.
6. Bathe the infant.

Show/hide explanation
1) CORRECT— Stabilizing the newborn and promoting thermoregulation of the newborn from intrauterine to extrauterine life is the priority of the nurse in the first minutes after an infant is born. Apgar performed at 1 and 5 min of life to assess infant’s transition to extrauterine life; cardiac rate, respirations, muscle tone, reflexes, and color are given 0 to 2 points each; score of 0 to 3 considered poor, 4 to 6 fair, 7 to 10 excellent.2) CORRECT— Part of newborn assessment.

3) Administering the Hepatitis B is done to stimulate immunity but is not completed in the first 10 minutes after birth.

4) CORRECT— Cap will prevent heat loss.

5) CORRECT— Priority action to ensure identify of the newborn.

6) Newborn is not bathed until the newborn’s temperature is stable.

Which post-delivery observations would alert the delivery room nurse to prepare to administer oxytocin (Pitocin) at a rate of 100 mL/hr (concentration of 30 units in 500 mL)?

Select all that apply.

1. The mother places her newborn to her breast.
2. There is a gush of blood from the mother’s vagina.
3. The mother’s systolic blood pressure drops 20 mm Hg.
4. The mother reports her uterus cramping.
5. The umbilical cord extends out of the vagina.

Show/hide explanation
1) While an infant suckling at the breast can stimulate the release of oxytocin and cause the placenta to separate, an infusion of Pitocin cannot be administered until the placenta has been expelled. Think cause and effect2) CORRECT— Pitocin should only be administered after the placenta separates from the uterine wall. The signs that placenta has separated are a gush of blood, the cord extending from the vagina, and the uterus contracting.

3) The blood pressure should not drop, as the patient has extra blood volume to compensate for the blood loss from delivery.

4) CORRECT— Pitocin should only be administered after the placenta separates from the uterine wall. The signs that placenta has separated are a gush of blood, the cord extending from the vagina, and the uterus contracting.

5) CORRECT— Indicates the placenta has separated from the uterus.

The nurse prepares to administer a client’s medications. The nurse reviews the “Rights of Medication Administration” with the student the nurse is precepting. The student names these rights. Which right does the nurse indicate as correct?

Select all that apply.

1. The nurse identifies the correct client.
2. The nurse identifies the client’s room number.
3. The nurse identifies the correct dose of medication.
4. The nurse identifies the correct route of medication.
5. The nurse identifies the correct time to administer the medication.
6. The nurse identifies the correct equipment to use to administer the medication.

Show/hide explanation
1) CORRECT — the six “Rights of Medication Administration” are the correct medication, dose, time, route, client, and documentation2) while the correct room number is necessary information to facilitate the administration of the medication, it is not considered one of the 6 rights of medication administration

3) CORRECT — one of the six “Rights of Medication Administration”

4) CORRECT — one of the six “Rights of Medication Administration”

5) CORRECT — one of the six “Rights of Medication Administration”

6) using the correct equipment will facilitate correctly administering the medication, but it is not part of the six “Rights of Medication Administration”

The nurse is in the medication room preparing to administer a medication IV push. Which medications are safe to administer IV push?

Select all that apply.

1. Ampicillin (Omnipen).
2. Vancomycin (Vancocin).
3. Potassium chloride.
4. Digitalis (Digoxin).
5. Furosemide (Lasix).
6. Mannitol (Osmitrol).

Show/hide explanation
1) CORRECT— Ampicillin is an antibiotic and can be given IV push. Medications given IV push need to be administered at the rate prescribed by the manufacturer, generally over 1 to 5 minutes. The purpose of administering IV push medications is to deliver medications rapidly for a prompt response.2) Vancomycin cannot be administered IV push. Vancomycin is administered at a rate of 10mg/min.

3) Potassium cannot be given IV push due to potentially lethal effect.

4) CORRECT— Cardiac glycoside. Can be administered IV push.

5) CORRECT— Loop diuretic. Can be administered IV push. Administer IV dose over 1 – 2 minutes. Diuresis begins in 5 – 10 minutes.

6) CORRECT— Osmotic diuretic. Can be administered IV push.

An unresponsive patient is admitted to the emergency department (ED). Reportedly, the patient is diabetic and recently self-administered insulin. Upon admission to the ED, the patient’s blood glucose is 26 mg/dL. The healthcare provider prescribes an IV bolus of Dextrose 50% (D50). The nurse is concerned about which of the following when administering D50?

Select all that apply.

1. Hypoglycemia.
2. Urine output.
3. Weight gain.
4. Hypertension.
5. Bradycardia.
6. Phlebitis.

Show/hide explanation
1) Hyperglycemia is common after a rapid administration of D50.2) CORRECT— Osmotic diuresis can occur with hyperglycemia, so urine output must be monitored closely.

3) Weight gain may be related to the diabetes, but would not occur because of administering D50.

4) If osmotic diuresis occurs, the patient may become hypotensive.

5) Heart palpitations and tachycardia are often symptoms seen with hypoglycemia.

6) CORRECT— D50 should be administered through a large bore needle, as extravasation of the solution can cause tissue sloughing and necrosis.

The nurse prepares oxytocin (Pitocin) for the client. Which supplies will the nurse need to prepare the prescribed Pitocin solution?

Select all that apply.

1. 5 mL syringe.
2. 19 gauge 1.5″ filter needle.
3. 20 gauge 1″ needle
4. Alcohol swab or gauze.
5. Non-sterile gloves.

Show/hide explanation
1) The best syringe to prepare this prescription is a 3 mL syringe. A 5 mL syringe lacks the calibration to safely withdraw the appropriate amount medication.2) CORRECT— A filter needle is indicated for drawing medication out of a vial. It is designed to filter out small particles of glass. However, the needle is only used to withdraw medications and NEVER to inject medications, as any glass that has been filtered may be injected.

3) CORRECT— After withdrawing the Pitocin, the nurse must change the needle to inject the medication into the IV bag.

4) CORRECT— An alcohol swab or gauze is necessary to place around the neck of the ampule to protect the nurse from being cut when snapping off the top of the ampule.

5) Non-sterile glove are not indicated when preparing this medication because there is no risk of contamination to the nurse during this procedure. Non-sterile gloves will be necessary when administering the medication.

The nurse provides care to the client with receiving parenteral nutrition (PN) with insulin through a central venous catheter. The nurse includes which actions in the client’s plan of care?

Select all that apply.

1. Monitor the client’s intake and output every shift.
2. Take the client’s weight every day at the same time.
3. Ensure a solution of 5% dextrose is available if a bag of PN is temporarily unavailable.
4. Change the PN tubing every 48 hours.
5. Have supplies for a finger stick blood glucose (FSBG) at the bedside.
6. Pre-calculate the “catch-up” rate if the PN infusion falls behind the prescribed rate

Show/hide explanation
1) CORRECT — a client receiving PN with insulin may develop osmotic diuresis if the blood glucose gets too high; monitoring intake and output (I & O) helps the nurse to determine fluid volume balance in the client receiving PN2) CORRECT — a client receiving PN with insulin may develop osmotic diuresis if the blood glucose gets too high; monitoring daily weights helps the nurse to determine fluid volume balance in the client receiving PN.

3) In the event a bag of PN is not readily available, the substitute solutions are D10W or D20W

4) PN tubing must be changed every 24 hours to decrease the risk of infection

5) CORRECT — because the client is receiving PN with insulin, FSBG supplies are necessary in the event of hyper/hypoglycemia

6) if the infusion of PN is behind prescribed rate, the infusion should never be infused faster; this action could result in shifts in fluid and electrolytes

The nurse instructs an 86-year-old client about foods high in fiber. The nurse determines teaching is effective if the client selects which foods?

Select all that apply.

1. Pears.
2. Unpeeled cucumber.
3. Split pea soup.
4. Sweet corn.
5. Raspberries.
6. Graham crackers.

Show/hide explanation
1) CORRECT— Fiber adds bulk, which aids in the elimination of food. Decreased peristalsis is common among the elderly, and bulk forming foods help decrease the risk of constipation. Fiber content in pears equals 4 grams.2) Fiber content in 10 slices of unpeeled cucumber equals 0.7 grams.

3) CORRECT— Fiber content in 1 cup of split pea soup equals 13.4 grams.

4) CORRECT— Fiber content in one ear of corn equals 5 grams.

5) CORRECT— Fiber content in .5 cup of raspberries equals 4.6 grams.

6) Fiber content in two graham crackers equals 1.4 grams.

The nurse prepares a teaching session for a community group on the detection, treatment, and modification of the risks for osteoarthritis (OA). Which community members are at greatest risk for developing osteoarthritis?

Select all that apply.

1. The 18-year-old who had a crushing foot injury in an automobile accident.
2. The 24-year-old who has worked in a coal mine for 6 years.
3. The 32-year-old who was treated for osteomyelitis 3 years ago.
4. The 35-year-old homemaker who is 5’4″ (162 cm) tall and weighs 185 pounds (84 kg).
5. The 56-year-old who is being treated for coronary artery disease.
6. The 64-year-old who plays tennis twice a week.

Show/hide explanation
1) CORRECT— Osteoarthritis is chronic joint disease involving progressive degenerative changes in articular cartilage covering joint surfaces and proliferation of bone and cartilage in joints. This client is at risk because of trauma to the joint.2) CORRECT— Occupations such as coal mining is a risk factor for developing osteoarthritis.

3) CORRECT— Bone infections are a risk factor for osteoarthritis.

4) CORRECT— Stress on weight-bearing joints due to obesity is a risk factor to develop osteoarthritis.

5) Coronary artery disease is not a risk factor for osteoarthritis.

6) Playing tennis increases bone density.

The nurse instructs the client newly diagnosed with type 1 diabetes about insulin. Which client statements demonstrate an understanding of insulin?

Select all that apply.

1. “I must eat before I administer the prescribed short-acting insulin.”
2. “Short-acting insulin will peak 1 to 5 hours after administration.”
3. “Short-acting insulin lasts about 6 to 10 hours.”
4. “Intermediate-acting insulin starts to work about 1 to 2 hours after administration.”
5. “Intermediate-acting insulin peaks 6 to 14 hours after administration.”
6. “Intermediate-acting insulin lasts 30 hours.”

Show/hide explanation
1) does not have to eat prior to the administration of short-acting insulin2) CORRECT — peak action 1-5 hours

3) CORRECT — duration 6-10 hours

4) CORRECT — onset of 1-2 hours

5) CORRECT — peak of 6-14 hours

6) duration of 16-24 hours

A nurse cares for clients diagnosed with depression in the mental health facility. Which comments, if made by clients to the nurse, concern the nurse?

Select all that apply.

1. “I am giving my best friend my favorite guitar.”
2. “I will never have to work on projects ever again.”
3. “I do not like to communicate through Facebook.”
4. “I have more energy than I had before coming here.”
5. “Why do you bother with me?”
6. “I have not slept in 2 days.”

Show/hide explanation
1) CORRECT— Warnings are common among those who are suicidal. The nurse needs to be aware of the warnings and act upon them to divert the patient from suicide. These warnings include giving away possessions.2) CORRECT— Wrapping up business affairs is another common warning that the client has suicidal ideation.

3) Isolation from friends is a warning sign that the client has suicidal ideation. Not participating in Facebook does not mean the client is isolating him/herself.

4) CORRECT— Often, people at risk for suicide more energy than they did previously, as they have made a decision and are working on following through with that decision.

5) CORRECT— Expressions of hopelessness and despair are possible warning signs of suicidal ideation.

6) While sleep deprivation is associated with depression, it s not a warning sign directly related to the risk for committing suicide.

The nurse working on a mental health unit describes the basics of therapeutic communication to a student. Which principles will the nurse include in the discussion with the student?

Select all that apply.

1. Therapeutic communication occurs in the workplace between both colleagues and clients.
2. Therapeutic communication occurs between the nurse and clients.
3. The purpose of therapeutic communication is to communicate observations and best practices in the clinical setting.
4. The content of therapeutic communication is primarily oriented to social conversation.
5. Therapeutic communication encourages the client to express thoughts, feelings, and anxieties.
6. The skills required for therapeutic communication are developed to use in only group settings.

Show/hide explanation
1) There are three overarching types of communication in a work setting: social, collegial, and therapeutic. Therapeutic communication occurs between nurse and client.2) CORRECT— Therapeutic communication occurs between the nurse and the client. The setting for therapeutic communication is private, quiet, confidential, and safe. The content encourages the patient to express thoughts, beliefs, feelings, anxieties, fears, and problems. The skills are developed professionally, and the healthcare provider receives specialized education about using therapeutic communication.

3) The purpose of therapeutic communication is to promote growth and change in clients.

4) Therapeutic communication is therapeutic.

5) CORRECT— The client is encouraged to express thoughts, beliefs, feelings, anxieties and fears. Therapeutic communication promotes growth and change in clients.

6) While therapeutic communication is used in a group setting, it is used any time the nurse is communicating with the client.

The clinic nurse reviews the chart of an 18-year-old client diagnosed with anorexia nervosa. Which notations in the chart support the healthcare provider’s diagnosis of anorexia nervosa?

Select all that apply.

1. The client’s daily intake consists of only cucumbers and carrots.
2. The client eats lunch at exactly 12:15 PM and supper at exactly 6:30 PM.
3. The client reports thinking of eating all the time.
4. The client’s heart rate of 122 beats per minute.
5. The client consumed an entire bag of potato chips in one sitting.
6. The client reports menorrhagia at age 13.

Show/hide explanation
1) CORRECT— Clients diagnosed with anorexia are often obsessive about what they eat, how much they eat, and when they eat. Intake may be as little as 200 cal/day.2) CORRECT—Clients diagnosed with anorexia are often obsessive about when they eat.

3) CORRECT—Clients diagnosed with anorexia become obsessed with food and exercise.

4) Some of the physical symptoms of people diagnosed with anorexia are amenorrhea, hypotension, constipation, muscle weakness, fatigue, cold intolerance, and bradycardia.

5) CORRECT— Reports of binging are common among people with the diagnosis of anorexia.

6) Menorrhagia is excessive and heavy menstrual periods. Amenorrhea is associated with anorexia.

The nurse in the emergency department assesses a client who reports a sudden onset of acute abdominal pain at a level of 9 out of 10. The client requests to be medicated with morphine. The same client has been in the emergency department 5 times in the past 2 weeks. The nurse is concerned that the client is demonstrating drug-seeking behaviors. Which notations in the client’s chart support the nurse’s concern?

Select all that apply.

1. Heart rate 74 beats per minute.
2. Blood pressure 114/72 mm Hg.
3. Sweat on the forehead.
4. Respiratory rate 28 per minute.
5. Pupil size 4.0 mm bilaterally.

Show/hide explanation
1) CORRECT— The physical symptoms of acute pain includes an increased heart rate.2) CORRECT— Increased blood pressure is an indication of pain.

3) While increased perspiration is a response to a painful stimuli, clients seeking drugs may participate in activities that cause client to sweat. Requesting a specific narcotic is another sign of drug seeking behavior.

4) Clients in pain will have elevated respirationswhich leads to increased oxygen supply to the brain and muscles.

5) CORRECT— . Normal pupil size is 2.0-5.0 mm. Physiological response to pain includes increased pupillary diameter which leads to increased eye accommodation to light.

The nurse plans to bathe the newborn for the first time. Place the steps for administering the newborn’s first bath in correct order, from first step to last step.

– Place the infant on a warm surface.
– Shampoo the hair/head.
– Cleanse the eyes from the inner canthus to the outer canthus.
– Wrap the infant in a towel or pre-warmed blanket.
– Cleanse the face using only warm water.
– Cleanse the body with warm water and a mild soap.

Correct response:
1- the infant on a warm surface.
2- Cleanse the eyes from the inner canthus to the outer canthus.
3- Cleanse the face using only warm water.
4- Cleanse the body with warm water and a mild soap.
5- Wrap the infant in a towel or pre-warmed blanket.
6- Shampoo the hair/head.Show/hide explanation
1) Step 1. Infants will lose heat during the bathing process, and the environment needs to be as warm as possible. Placing the infant on a warmed surface will help prevent heat loss through conduction. The process proceeds cephalocaudal (head-to-toe) with warm water and a mild soap.

2) Step 6. The infant will lose most of its heat from the head. The head should be washed last while the infant is wrapped in a warm blanket or towel to decrease the amount of heat loss.

3) Step 2. Completed after placing the infant on a warmed surface. The eyes are first, and each eye is washed with a clean washcloth or cotton ball with only warm water.

4) Step 5. Place the infant on warmed surface, cleanse the eyes from the inner canthus to the outer canthus, cleanse the face with warm water only, and cleanse the body with warm water and a mild soap. Place infant in warmed blanket.

5) Step 3. The face is washed with warm water only. Completed after placing the infant on a warmed surface and cleansing the eyes from inner canthus to the outer canthus.

6) Step 4. Completed after placing the infant on a warmed surface, cleansing eyes from the inner canthus to the outer canthus, and cleansing the face with warm water only.

An 88-year-old patient has two units of packed blood cells ordered for transfusion. Place the nursing actions to safely administer the blood in correct order, from first step to last step.

– Double verify the compatibility of the ordered blood to the patient’s blood type.
– Evaluate for transfusion reactions.
– Ensure the patency of the primary IV line.
– Review the chart for informed consent.
– Initiate the transfusion.
– Identify the patient.

Correct response:
1) Review the chart for informed consent.
2) Ensure the patency of the primary IV line.
3) Double verify the compatibility of the ordered blood to the patient’s blood type.
4) Identify the patient.
5) Initiate the transfusion.
6) Evaluate for transfusion reactions.Show/hide explanation
1) Step 3. Completed after reviewing the chart for informed consent and ensuring patency of the primary IV line.

2) Step 6. Most reactions will occur within the administration of the first 50 mL of the blood. The nurse must most closely monitor the patient for a transfusion reaction during

3) Step 2. The patient must have a patent IV line to initiate the administration of any blood product. Completed after reviewing the chart for informed consent.

4) Step 1. No kind of procedure can be initiated without the patient’s consent, whether written or verbal. Therefore, this is the first step in the process. Without consent, there is no need for the remaining steps in the process.

5) Step 5. Immediately before administration, it is the responsibility of the nurse administering the blood to assure the product is compatible with the patient, and this must be double checked with another healthcare provider.

6) Step 4. Immediately before the correct blood product is piggy-backed into the primary IV system, the patient must be identified using no less than two patient identifiers. The nurse can then initiate the blood and evaluate for any type of transfusion reaction.

The nurse monitors the administration of packed red blood cells. The patient reports back pain and chills. Place the nursing actions in response to the patient’s report in correct order, from first action to last action.

– Collect a urine sample.
– Notify the healthcare provider.
– Infuse normal saline (NS).
– Return the blood to the blood bank.
– Stop the transfusion.

Correct Response:
1) Stop the transfusion.
2) Infuse normal saline (NS).
3) Notify the healthcare provider.
4) Collect a urine sample.
5) Return the blood to the blood bank.Show/hide explanation
1) Action 4. The order of actions is: 1) The nurse must first address the cause by stopping the blood. 2) The IV needs to be maintained in the anticipation of delivering lifesaving medications, so the NS need to infuse to endure IV patency and prevent hemolysis of any blood that may still be in the system. 3) The healthcare provider may order antihistamines, vasopressors, or steroids, and therefore must be contacted. 4) Collect a urine sample to evaluate for hematuria (this is a patient mediated action). 5) The last action is returning the blood to the blood bank for further analysis for the cause of the reaction.

2) Action 3. The order of actions is: 1) The nurse must first address the cause by stopping the blood. 2) The IV needs to be maintained in the anticipation of delivering lifesaving medications, so the NS need to infuse to endure IV patency and prevent hemolysis of any blood that may still be in the system. 3) The healthcare provider may order antihistamines, vasopressors, or steroids, and therefore must be contacted. 4) Collect a urine sample to evaluate for hematuria (this is a patient mediated action). 5) The last action is returning the blood to the blood bank for further analysis for the cause of the reaction.

3) Action 2. The order of actions is: 1) The nurse must first address the cause by stopping the blood. 2) The IV needs to be maintained in the anticipation of delivering lifesaving medications, so the NS need to infuse to endure IV patency and prevent hemolysis of any blood that may still be in the system. 3) The healthcare provider may order antihistamines, vasopressors, or steroids, and therefore must be contacted. 4) Collect a urine sample to evaluate for hematuria (this is a patient mediated action). 5) The last action is returning the blood to the blood bank for further analysis for the cause of the reaction.

4) Action 5.

5) Initial action.

The nurse prepares to leave a client’s room after providing care. The nurse is wearing full personal protective equipment (PPE). In which order does the nurse remove the PPE, from the first step to the last step? All choices must be used.

– Remove gloves.
– Remove eyewear.
– Untie strings of gown.
– Fold gown inside out.
– Remove mask.

Correct Response:
1) Remove gloves.
2) Remove eyewear.
3) Untie strings of gown.
4) Fold gown inside out.
5) Remove mask.Show/hide explanation
Strategy: Think about why you would complete each step before another step. Determine first and last step then fill in the middle.

1) step 1: the gloves are likely the most contaminated object of the PPE and need to be removed first

2) step 2: the purpose of PPE is to protect the nurse from harmful pathogens and prevent the spread of pathogens; gloves are likely the most contaminated object and are removed first followed by the protective eyewear

3) step 3: strings of the gown are untied after removing gloves and protective eyewear

4) step 4: remove gloves first, then the eyewear; next, the strings of the gown are untied and the gown is folded on itself so it is inside out

5) step 5: remove mask last

The healthcare provider has prescribed 15 units of Regular insulin and 22 units of NPH insulin for the newly diagnosed diabetic. The nurse reviews the method for mixing insulin with the patient. Place the steps for mixing insulin in correct order, from first step to last step.

– Inject the equivalent of 22 units of air into the vial of NPH insulin.
– Draw into the syringe the equivalent of 37 units of air.
– Draw out 22 units of NPH insulin.
– Draw out 15 units of regular insulin.
– Inject the equivalent of 15 units of air into the vial of regular insulin.

Correct response:
1) Draw into the syringe the equivalent of 37 units of air.
2) Inject the equivalent of 22 units of air into the vial of NPH insulin.
3) Inject the equivalent of 15 units of air into the vial of regular insulin.
4) Draw out 15 units of regular insulin.
5) Draw out 22 units of NPH insulin.Show/hide explanation
1) Step 2. The amount of medication drawn out of the vial must first be displaced with an equivalent amount of air.

2) Step 1. The total amount of air required is 37 units (22 NPH and 15 units for the regular insulin.

3) Step 5. Regular insulin is drawn up first and then the NPH insulin. This is to prevent NPH insulin from inadvertently getting mixed into a vial of Regular insulin.

4) Step 4. When mixing insulin, regular insulin is drawn up before the NPH insulin.

5) Step 3. Insert air into the NPH vial first and then the vial of regular insulin. Regular insulin can then be withdrawn.

The nurse plans to insert a Foley catheter in a female patient. Place the steps for the insertion of the catheter in correct order, from first step to last step

– Advance the catheter 2-3 inches or until urine flows.
– Position the client with the perineal area exposed.
– Inflate the balloon as per the manufacturer’s instructions.
– Wipe the perineal area from front to back with a cotton ball saturated with an antibacterial solution.
– Cleanse the genital area with soap and water.
– Expose the urethral meatus.

Correct:
1) Cleanse the genital area with soap and water.
2) Position the client with the perineal area exposed.
3) Expose the urethral meatus.
4) Wipe the perineal area from front to back with a cotton ball saturated with an antibacterial solution.
5) Advance the catheter 2-3 inches or until urine flows.
6) Inflate the balloon as per the manufacturer’s instructions.Show/hide explanation
1) Step 5. Completed after cleansing the genital area with soap and water, positioning the client with perineal area exposed, exposing the urethral meatus, and wiping the perineal area from front to back with a cotton ball saturated with an antibacterial solution. Insertion of a Foley catheter is a sterile procedure and the source of many hospital acquired infections. Proper care and maintenance of sterile technique is imperative to decrease the risk of infection.

2) Step 2. Completed after cleansing the genital area with soap and water.

3) Step 6. Balloon is no longer pre-inflated as per evidence-based practice. Pre-inflating the balloon can lead to additional trauma during the insertion procedure from not withdrawing all of the fluid or ridges created in the balloon from the inflation.

4) Step 4. Completed after cleansing the genital area, positioning the client with the perineal area exposed, and exposing the urethral meatus.

5) Step 1.

6) Step 3. Completed after cleansing the genital area with soap and water, positioning the client with the perineal area exposed, and wiping the perineal area from front to back with a cotton ball saturated with an antibacterial solution.

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