Module 3 Week 11 Skills & Precedures Exam

A 74-year-old client with pneumonia and a history of congestive heart failure is admitted to a medical-surgical unit. The client has a peripheral IV line for administration of antibiotics and maintenance fluids. The nurse is reviewing best practices for IV therapy to promote safety and reduce the risk of nosocomial infections. Which of the following nursing actions are appropriate or not appropriate? Select the most appropriate classification for each action. Verify the IV solution type and flow rate with the primary provider's prescription. Change the venipuncture site every 48 hours. Let the IV solution bag hang for 48 hours to avoid waste. Change the IV tubing every 96 hours or with a site change. Replace a damp IV dressing with a new sterile one. Apply a transparent dressing over a gauze dressing already covering the IV site. Flush the peripheral IV with sterile saline before connecting a new antibiotic bag.

A 58-year-old client with severe Crohn's disease is receiving total parenteral nutrition (TPN) via a central venous catheter. During the evening shift, the nurse is responsible for managing the TPN infusion and evaluating for complications. Midway through the shift, the infusion pump malfunctions and stops. The nurse notes the client is lethargic, pale, and diaphoretic. A bedside capillary blood glucose reading is 54 mg/dL. Which action should the nurse take first?. Notify the primary healthcare provider. Administer 10% dextrose in water (D10W) at the same rate as the TPN. Re-prime the TPN tubing and restart the infusion. Assess the client's vital signs.

A 72-year-old client with a small bowel obstruction is scheduled for nasogastric (NG) tube insertion for gastric decompression. The nurse prepares to perform the procedure at the bedside. The client is alert and able to follow instructions. Which of the following actions should the nurse implement during the insertion of the NG tube? Select all that apply. Instruct the client to hyperextend the neck during tube advancement. Measure the tube from the tip of the nose to the earlobe and then to the xiphoid process. Apply water-soluble lubricant to the distal end of the NG tube. Instruct the client to take sips of water and swallow as the tube is advanced. Confirm placement by auscultating for a whooshing sound after injecting air into the tube. Advance the NG tube quickly without pausing to reduce client discomfort.

The nurse is caring for four clients. The nurse must determine which client to assess first?. A 66-year-old client with an NG tube set to low intermittent suction who reports mild nausea and abdominal bloating. A 72-year-old client receiving intermittent NG feedings with residual volume of 60 mL and hypoactive bowel sounds. A 70-year-old client with an NG tube whose output has become sanguineous in appearance and has increased to 200 mL over the past two hours. A 68-year-old client awaiting NG tube placement who reports hunger and asks when the procedure will begin.

A 64-year-old client with a tracheostomy is receiving mechanical ventilation following abdominal surgery. The nurse notes that the client is exhibiting audible gurgling sounds, increased respiratory rate, and decreased oxygen saturation. The nurse prepares to perform tracheal suctioning. Which of the following actions are appropriate or inappropriate during tracheal suctioning? Select one response for each row. Preoxygenate the client with 100% oxygen before suctioning. Apply continuous suction while inserting the catheter. Use sterile technique throughout the procedure. Limit each suction pass to no more than 10 seconds. Once the catheter is inserted, apply continuous suction while withdrawing the catheter. Using the same catheter to suction the mouth after tracheal suctioning.

A 70-year-old client with a tracheostomy tube is recovering from a recent stroke. The nurse is implementing interventions to prevent accidental dislodgment of the tracheostomy tube. Which of the following nursing actions help prevent tracheostomy tube dislodgment? Select all that apply. Secure the tube in place using appropriate tracheostomy ties or holders. Routinely reposition the tracheostomy tube to reduce pressure on the skin. Minimize unnecessary manipulation or traction on the tracheostomy tube. Keep the head of the bed elevated to 30 to 45 degrees unless contraindicated. Restrain the client's hands at all times to prevent accidental removal. Monitor the client closely and remind them not to touch the tracheostomy tube. Ensure a replacement tracheostomy tube of the same size and type is readily available at the bedside.

A 68-year-old client is 48 hours post-tracheostomy placement. The nurse observes signs of potential tube dislodgment: difficulty breathing, restlessness, noisy respirations, and audible stridor. Which of the following nursing interventions are appropriate, inappropriate, or require clarification? Select one classification per row. Immediately attempt to reinsert the dislodged tracheostomy tube. Manually ventilate the client using a resuscitation (Ambu) bag. Call for the Rapid Response Team to obtain emergency assistance. Extend the client's neck and open the tissues of the stoma to secure the airway. Use a tracheal dilator to hold the stoma open. Assess the client's breath sounds and prepare for possible intubation.

A 60-year-old client with a pneumothorax has a chest tube connected to a closed drainage system. The nurse is performing routine care and monitoring the function of the system. Which of the following nursing actions are appropriate during routine post-insertion care of a client with a chest tube drainage device? Select all that apply. Temporarily elevate the chest tube drainage system above chest level during ambulation. Keep the drainage system below the level of the client's chest at all times. Strip the chest tube regularly to prevent clogging. Observe for tidaling in the water-seal chamber during inhalation and exhalation. Milk the chest tube only if prescribed and signs of obstruction are present. Secure all tubing connections with tape or locking devices.

A 64-year-old client on mechanical ventilation suddenly triggers an alarm. The nurse assesses the client and ventilator settings. Which of the following findings are causes of a high-pressure alarm or a low-pressure alarm on a mechanical ventilator? Select the most appropriate classification for each finding. Kinked ventilator tubing. Client stops spontaneous breathing. Increased pulmonary secretions in airway. Ventilator tubing becomes disconnected. Client bites the endotracheal tube. Airway cuff leak. Client is anxious and fighting the ventilator.

A 70-year-old client receiving total parenteral nutrition (TPN) via a central line suddenly develops chest pain, dyspnea, and a weak, rapid pulse. On auscultation, the nurse hears a loud churning sound over the pericardium. Which of the following interventions and preventive actions are appropriate or not appropriate in response to this client's condition? Select one classification per row. Clamp all ports of the IV catheter immediately. Place the client in a left side-lying position with the head lower than the feet. Instruct the client to breathe slowly and deeply to relax. Notify the primary healthcare provider (PHCP) promptly. Instruct the client to perform the Valsalva maneuver. Administer 100% oxygen via non-rebreather mask as prescribed. Leave the catheter site open to air while changing the tubing.

A 72-year-old client has just undergone the insertion of a central venous catheter for the initiation of parenteral nutrition (PN). Within one hour, the client reports acute chest pain and sudden shortness of breath. On assessment, the nurse notes tachycardia, cyanosis, and absent breath sounds on the right side. Complete the following statements by selecting the correct option from the drop-down menu in each blank. The nurse suspects the client is experiencing a complication known as _____. The nurse should immediately notify the ______. A chest _____ should be obtained to confirm the diagnosis. Parenteral nutrition should be _____. Based on the client's symptoms and assessment findings, if imaging confirms a small pleural air collection, the nurse should ______.

A 65-year-old client with symptomatic anemia is scheduled to receive a unit of packed red blood cells (PRBCs). The nurse is reviewing general blood administration precautions to ensure safe practice. Which of the following nursing actions are appropriate during the preparation, initiation, and monitoring of a blood transfusion? Select all that apply. Inspect the blood bag for leaks, clots, and expiration date before transfusion. Begin transfusion within 20 to 30 minutes of receiving blood from the blood bank. Use lactated Ringer's solution to flush the IV line before starting the transfusion. Monitor and record vital signs before, 15 minutes after starting, and during the transfusion. Infuse the blood slowly over 6 hours to minimize fluid overload risk. Return blood to the blood bank if it is not started within 30 minutes. Administer IV medications through the same IV line as the transfusion.

A 56-year-old client is admitted with abdominal distention, nausea, and absence of bowel sounds. A nasogastric (NG) tube is prescribed for gastric decompression. The nurse prepares for NG tube insertion and reviews agency procedures. Based on this scenario, which actions should the nurse implement when inserting and managing the NG tube? Select all that apply. Lubricate the tip of the tube with petroleum-based lubricant. Measure the tube from nose to earlobe to xiphoid process before insertion. Instruct the client to tilt the head backward while the tube passes through the oropharynx. Confirm tube placement by obtaining an abdominal x-ray after insertion. Aspirate stomach contents and test pH before instilling any substance. Advance the tube if the client begins to cough or show signs of respiratory distress.

A 72-year-old client with a history of stroke is receiving enteral nutrition via a nasogastric tube. The nurse is preparing to administer a scheduled feeding. Which interventions should the nurse implement when administering enteral nutrition? Select all that apply. Administer bolus feedings over 5 minutes to mimic normal mealtimes. Hold feeding and notify the provider if bowel sounds are absent. Warm the feeding to room temperature before administration. Keep the client in a high-Fowler's position during and 15 minutes after bolus feeding. Use a feeding pump for both continuous and cyclic feedings. Skip checking gastric residual if the previous feeding was well tolerated. Administer cold formula to reduce bacterial growth risk.

A nurse is preparing to administer a prescribed medication through a client's nasogastric tube. The nurse has verified the client's identity using two identifiers and confirmed that the medication can be safely crushed. Which action should the nurse take next?. Flush the tube with 60 mL of cold water. Administer the medication directly into the feeding bag. Check tube placement and assess for bowel sounds. Clamp the tube for 60 minutes before administering the medication.

A 68-year-old client has a newly placed tracheostomy following prolonged intubation. The nurse is monitoring the client's respiratory status and tracheostomy care. Which findings require immediate nursing intervention? Select all that apply. Oxygen saturation of 95% on humidified oxygen. Presence of subcutaneous crepitus around the tracheostomy site. Small amount of clear, thin secretions around the stoma. Client speaking a few words while cuff is inflated. Client reports difficulty breathing and absence of breath sounds in the right lung. Cuff pressure is 20 mm Hg.

A nurse is preparing to perform tracheal suctioning on a 70-year-old client with pneumonia who has a productive cough, increased secretions, and diminished breath sounds. The client is receiving 40% humidified oxygen via tracheostomy collar and has a baseline SpO2 of 94%. The nurse has completed hand hygiene, donned PPE, and prepared the suction equipment. Which action should the nurse take immediately before inserting the suction catheter?. Administer a bronchodilator to minimize coughing during the procedure. Assess the color, consistency, and volume of the client's sputum. Hyperoxygenate the client. Measure the suction catheter length against the tracheostomy tube and mark the depth with tape.

The nurse receives reports on four clients during the morning shift. Which client should the nurse assess first?. A 67-year-old client who had a new tracheostomy placed 3 hours ago and is receiving humidified oxygen at 40%. A 59-year-old client who had a nasogastric tube placed for feeding yesterday and is due for a residual volume check. A 72-year-old client who received tracheal suctioning 30 minutes ago and currently has an SpO2 of 96%. A 70-year-old client with a PEG tube scheduled for routine medication administration in 15 minutes.

The nurse is evaluating four clients in the intensive care unit (ICU). Which client requires immediate assessment based on clinical findings?. A 78-year-old client who is one-hour post-tracheal suctioning and is now drowsy but arousable with SpO2 of 93% on humidified oxygen. A 62-year-old client who has had a PEG tube dislodged during transfer and is awaiting a new tube insertion order from the provider. A 70-year-old client who had a central venous catheter placed 30 minutes ago and reports mild chest discomfort and shortness of breath. A 65-year-old client who is receiving continuous tube feeding and has a gastric residual volume of 180 mL upon routine check.

The ICU nurse is prioritizing care for four clients. The nurse must determine which client requires immediate assessment and intervention. A 58-year-old client 4 hours post central line insertion now reporting sudden onset of dyspnea, chest pain, and decreased breath sounds on the right side. A 76-year-old client 30 minutes post lumbar puncture who reports a severe headache and blurred vision. A 69-year-old client with a PICC line who is receiving antibiotics and reports warmth and tenderness at the insertion site. A 71-year-old client who had a Foley catheter placed an hour ago and now reports lower abdominal cramping and urgency to void.