Question 1

The nurse is administering an iron medication to a client via the Z-track method. Which guidelines/steps are recommended for this procedure? Select all that apply.

Accepted Answer

A)  Use the Z-track method only in the deltoid site. 
B)  Pinch the skin of the injection site to raise the site. 
C)  Insert the needle, aspirate, and inject the medication. 
D)  Quickly remove the needle after injecting the medication. 
E)  Do not massage the injection site.
F) Allow the skin to return to its original position slowly, while removing the needle. 
A)  Use the Z-track method only in the deltoid site. 
B)  Pinch the skin of the injection site to raise the site. 
C)  Insert the needle, aspirate, and inject the medication. 
D)  Quickly remove the needle after injecting the medication. 
E)  Do not massage the injection site.
F) Allow the skin to return to its original position slowly, while removing the needle. C, E, F

Question 2

A nurse is administering an IM injection of diphtheria-tetanus with pertussis (DTaP) to a 4-month-old infant. What would be the appropriate site for this injection?

Accepted Answer

A)  Dorsal gluteal 
B)  Ventrogluteal 
C)  Deltoid 
D)  Vastus lateralis 
A)  Dorsal gluteal 
B)  Ventrogluteal 
C)  Deltoid 
D)  Vastus lateralis D

Question 3

The nurse is teaching a student nurse how to draw medications into a syringe. In what part of the syringe would the medications be drawn?

Accepted Answer

A)  Tip 
B)  Barrel 
C)  Plunger 
D)  Needle 
A)  Tip 
B)  Barrel 
C)  Plunger 
D)  Needle B

Question 4

Which guideline is recommended to prevent needlestick injuries when injecting clients?

Accepted Answer

A)  If using a safety syringe, following an injection, the nurse should push in the sheath and twist until it clicks. 
B)  If using a safety syringe with an articulated type sheath, following an injection the nurse should use the thumb to push the sheath over the needle. 
C)  If using a safety syringe, the nurse should recap the needle using the "scoop method" in which the fingers do not touch the needle. 
D)  If a safety syringe is not available, the needle can be injected into a special cap, the Point-Loc device, which locks the tip of the needle in place. 
A)  If using a safety syringe, following an injection, the nurse should push in the sheath and twist until it clicks. 
B)  If using a safety syringe with an articulated type sheath, following an injection the nurse should use the thumb to push the sheath over the needle. 
C)  If using a safety syringe, the nurse should recap the needle using the "scoop method" in which the fingers do not touch the needle. 
D)  If a safety syringe is not available, the needle can be injected into a special cap, the Point-Loc device, which locks the tip of the needle in place.

Question 5

The nurse is converting a client's continuous IV infusion to a saline lock. Which guideline is recommended for this procedure?

Accepted Answer

A)  Stop the infusion and unclamp the tube to allow air to flow out of the line. 
B)  Replace the primary IV tubing with a PICC line. 
C)  Flush the lock with 2 to 3 mL of heparin every 4 hours to prevent clogging. 
D)  Flush the lock with 2 to 3 mL of saline every 8 hours or as ordered. 
A)  Stop the infusion and unclamp the tube to allow air to flow out of the line. 
B)  Replace the primary IV tubing with a PICC line. 
C)  Flush the lock with 2 to 3 mL of heparin every 4 hours to prevent clogging. 
D)  Flush the lock with 2 to 3 mL of saline every 8 hours or as ordered.

Question 6

The nurse who is monitoring an IV site for a client receiving normal saline watches out for the signs and symptoms of infiltration. Which is a sign of this adverse condition?

Accepted Answer

A)  Swelling 
B)  Skin hot to the touch 
C)  Feeling of softness in the area 
D)  No fluid evident around the catheter 
A)  Swelling 
B)  Skin hot to the touch 
C)  Feeling of softness in the area 
D)  No fluid evident around the catheter

Question 7

A nurse is administering medication to a client using an intravenous (IV) infusion. What considerations should be kept in mind when using infusion pumps?

Accepted Answer

A)  Infusion pumps use gravity to maintain the flow of IV fluids at a preset rate. 
B)  Infusion pumps are used in clients with kidney disease to prevent fluid overload. 
C)  Infusion pumps automatically regulate the rate and amount of IV fluid. 
D)  Infusion pumps do not pump fluids when the catheter is displaced from the vein. 
A)  Infusion pumps use gravity to maintain the flow of IV fluids at a preset rate. 
B)  Infusion pumps are used in clients with kidney disease to prevent fluid overload. 
C)  Infusion pumps automatically regulate the rate and amount of IV fluid. 
D)  Infusion pumps do not pump fluids when the catheter is displaced from the vein.

Question 8

The nurse is performing venipuncture on a client to obtain blood for ordered tests. Which guideline is recommended for this procedure?

Accepted Answer

A)  Apply the tourniquet about 4 to 6 in above the proposed site. 
B)  Check for the presence of an apical pulse and locate a peripheral vein. 
C)  Ask the client to open and close the fist, ending with an open fist. 
D)  If a vein is difficult to access, raise the arm above the level of the heart. 
A)  Apply the tourniquet about 4 to 6 in above the proposed site. 
B)  Check for the presence of an apical pulse and locate a peripheral vein. 
C)  Ask the client to open and close the fist, ending with an open fist. 
D)  If a vein is difficult to access, raise the arm above the level of the heart.

Question 9

A nurse is caring for several clients receiving fluids through central venous catheters. For which client could a Broviac-tunneled central venous catheter be used?

Accepted Answer

A)  A client who needs a blood transfusion 
B)  A client who needs a saline infusion 
C)  A client who needs TPN 
D)  A client who is receiving CPN 
A)  A client who needs a blood transfusion 
B)  A client who needs a saline infusion 
C)  A client who needs TPN 
D)  A client who is receiving CPN

Question 10

What guidelines should the nurse follow when performing an allergy skin test?

Accepted Answer

A)  Choose an injection site that is taut and heavily pigmented. 
B)  Withdraw the needle at the same angle at which it was inserted. 
C)  Place the needle, bevel down, on the skin surface at about a 45-degree angle. 
D)  Ask the client to rub the insertion site after withdrawing the needle. 
A)  Choose an injection site that is taut and heavily pigmented. 
B)  Withdraw the needle at the same angle at which it was inserted. 
C)  Place the needle, bevel down, on the skin surface at about a 45-degree angle. 
D)  Ask the client to rub the insertion site after withdrawing the needle.

Question 11

A nurse is caring for a client diagnosed with pancreatic disease. The client is receiving total parenteral nutrition (TPN) to help maintain adequate levels of carbohydrates, proteins, fats, vitamins, minerals, water, and electrolytes. Which measure should the nurse follow when providing TPN?

Accepted Answer

A)  Perform insertion of a central line under aseptic conditions. 
B)  Check the client's vital signs for evidence of developing infection. 
C)  Avoid folding the tape over when securing the catheter. 
D)  Measure the blood glucose level at the end of the day. 
A)  Perform insertion of a central line under aseptic conditions. 
B)  Check the client's vital signs for evidence of developing infection. 
C)  Avoid folding the tape over when securing the catheter. 
D)  Measure the blood glucose level at the end of the day.

Question 12

The nurse is preparing to administer an IV infusion to a client. Which step is recommended in this procedure?

Accepted Answer

A)  Place the client in a side-lying position. 
B)  Invert the bag and spike it with the IV tubing. 
C)  Prime the tubing and squeeze the drip chamber until it is full of IV fluid. 
D)  When blood enters the venous access device, advance the needle to half its length. 
A)  Place the client in a side-lying position. 
B)  Invert the bag and spike it with the IV tubing. 
C)  Prime the tubing and squeeze the drip chamber until it is full of IV fluid. 
D)  When blood enters the venous access device, advance the needle to half its length.

Question 13

The nurse is administering an injectable medication for a client who is unconscious and unable to swallow oral medications. What are other reasons that injectable medications may be ordered? Select all that apply.

Accepted Answer

A)  The medication is more effective by injection. 
B)  The client needs the desired action to occur slowly. 
C)  The medication is not available by any other route. 
D)  The client must obtain the entire dose. 
E)  The digestive system absorbs the drug too quickly.
F) The client is nauseated or vomiting. 
A)  The medication is more effective by injection. 
B)  The client needs the desired action to occur slowly. 
C)  The medication is not available by any other route. 
D)  The client must obtain the entire dose. 
E)  The digestive system absorbs the drug too quickly.
F) The client is nauseated or vomiting.

Question 14

The nurse is ordered to infuse 1,000 mL of normal saline in 8 hours. What would the nurse calculate to be the number of drops to be delivered per minute?

Accepted Answer

A)  75 
B)  100 
C)  125 
D)  150 
A)  75 
B)  100 
C)  125 
D)  150

Question 15

A nurse injecting a client diagnosed with HIV/AIDS is accidentally stuck with the needle. What action is included in the protocol when this type of incident occurs?

Accepted Answer

A)  The employer must be notified in writing within 3 days. 
B)  An incident report must be filed immediately. 
C)  The nurse must receive treatment for the infection within 1 week. 
D)  Blood tests for the nurse should be repeated in 3 months. 
A)  The employer must be notified in writing within 3 days. 
B)  An incident report must be filed immediately. 
C)  The nurse must receive treatment for the infection within 1 week. 
D)  Blood tests for the nurse should be repeated in 3 months.

Question 16

A client diagnosed with pneumonia has been prescribed an antibiotic that is to be administered rapidly. The client is also at risk for fluid overload. Which IV device would most likely be used for this client?

Accepted Answer

A)  IV piggyback (IVP
B)  
B)  Volume-controlled infusion 
C)  IV bolus 
D)  Saline lock 
A)  IV piggyback (IVP
B)  
B)  Volume-controlled infusion 
C)  IV bolus 
D)  Saline lock

Question 17

Which medication would not be delivered via patient-controlled analgesia (PCA) or portable pump?

Accepted Answer

A)  Morphine 
B)  Fentanyl 
C)  Insulin 
D)  Vancomycin 
A)  Morphine 
B)  Fentanyl 
C)  Insulin 
D)  Vancomycin

Question 18

The nurse is preparing a syringe using medication from a vial. Which guideline is recommended for this procedure?

Accepted Answer

A)  Remove the cover from the vial and clean with soapy water. 
B)  Draw an amount of air into the syringe equal to medication needed. 
C)  Insert needle through side of stopper and draw medication into the barrel. 
D)  Pull back on the syringe's plunger and fill the barrel completely with the medication. 
A)  Remove the cover from the vial and clean with soapy water. 
B)  Draw an amount of air into the syringe equal to medication needed. 
C)  Insert needle through side of stopper and draw medication into the barrel. 
D)  Pull back on the syringe's plunger and fill the barrel completely with the medication.

Question 19

The nurse is administering a tuberculin test (PPD skin test) to a client. What method of injection should the nurse use for this type of testing?

Accepted Answer

A)  Intradermal 
B)  Subcutaneous 
C)  Intramuscular 
D)  Intravenous 
A)  Intradermal 
B)  Subcutaneous 
C)  Intramuscular 
D)  Intravenous

Question 20

The nurse is giving an IM corticosteroid injection to a client with rheumatoid arthritis. What type of syringe and needle would the nurse use for this injection?

Accepted Answer

A)  2- to 3-mL syringe with 1- to 2-in needle 
B)  1-mL tuberculin syringe with 3/8-in bevel 
C)  2- to 3-mL syringe with 1- to 11/2-in needle 
D)  1- to 2-mL syringe with 3/8- to 1-in needle 
A)  2- to 3-mL syringe with 1- to 2-in needle 
B)  1-mL tuberculin syringe with 3/8-in bevel 
C)  2- to 3-mL syringe with 1- to 11/2-in needle 
D)  1- to 2-mL syringe with 3/8- to 1-in needle

Exam 64: Normal Pregnancy

The nurse is administering an iron medication to a client via the Z-track method. Which guidelines/steps are recommended for this procedure? Select all that apply.

A nurse is administering an IM injection of diphtheria-tetanus with pertussis (DTaP) to a 4-month-old infant. What would be the appropriate site for this injection?

The nurse is teaching a student nurse how to draw medications into a syringe. In what part of the syringe would the medications be drawn?

Which guideline is recommended to prevent needlestick injuries when injecting clients?

The nurse is converting a client's continuous IV infusion to a saline lock. Which guideline is recommended for this procedure?

The nurse who is monitoring an IV site for a client receiving normal saline watches out for the signs and symptoms of infiltration. Which is a sign of this adverse condition?

A nurse is administering medication to a client using an intravenous (IV) infusion. What considerations should be kept in mind when using infusion pumps?

The nurse is performing venipuncture on a client to obtain blood for ordered tests. Which guideline is recommended for this procedure?

A nurse is caring for several clients receiving fluids through central venous catheters. For which client could a Broviac-tunneled central venous catheter be used?

What guidelines should the nurse follow when performing an allergy skin test?

A nurse is caring for a client diagnosed with pancreatic disease. The client is receiving total parenteral nutrition (TPN) to help maintain adequate levels of carbohydrates, proteins, fats, vitamins, minerals, water, and electrolytes. Which measure should the nurse follow when providing TPN?

The nurse is preparing to administer an IV infusion to a client. Which step is recommended in this procedure?

The nurse is administering an injectable medication for a client who is unconscious and unable to swallow oral medications. What are other reasons that injectable medications may be ordered? Select all that apply.

The nurse is ordered to infuse 1,000 mL of normal saline in 8 hours. What would the nurse calculate to be the number of drops to be delivered per minute?

A nurse injecting a client diagnosed with HIV/AIDS is accidentally stuck with the needle. What action is included in the protocol when this type of incident occurs?

A client diagnosed with pneumonia has been prescribed an antibiotic that is to be administered rapidly. The client is also at risk for fluid overload. Which IV device would most likely be used for this client?

Which medication would not be delivered via patient-controlled analgesia (PCA) or portable pump?

The nurse is preparing a syringe using medication from a vial. Which guideline is recommended for this procedure?

The nurse is administering a tuberculin test (PPD skin test) to a client. What method of injection should the nurse use for this type of testing?

The nurse is giving an IM corticosteroid injection to a client with rheumatoid arthritis. What type of syringe and needle would the nurse use for this injection?

The Origins of Nursing

Beginning Your Nursing Career

The Healthcare Delivery System

Legal and Ethical Aspects of Nursing

Basic Human Needs

Health and Wellness

Community Health

Transcultural Healthcare

The Family

Infancy and Childhood

Adolescence

Early and Middle Adulthood

Older Adulthood and Aging

Death and Dying

Organization of the Human Body

The Integumentary System

Fluid and Electrolyte Balance

The Musculoskeletal System

The Nervous System

The Endocrine System

The Sensory System

The Cardiovascular System

The Hematologic and Lymphatic Systems

The Immune System

The Respiratory System

The Digestive System

The Urinary System

The Male Reproductive System

The Female Reproductive System

Basic Nutrition

Transcultural and Social Aspects of Nutrition

Diet Therapy and Special Diets

Introduction to the Nursing Process

Nursing Assessment

Nursing Diagnosis and Planning

Implementing and Evaluating Care

Documenting and Reporting

The Healthcare Facility Environment

Emergency Preparedness

Introduction to Microbiology

Medical Asepsis

Infection Control

Emergency Care and First Aid

Therapeutic Communication Skills

Admission, Transfer, and Discharge

Vital Signs

Data Collection in Client Care

Body Mechanics and Positioning

Beds and Bed Making

Personal Hygiene and Skin Care

Elimination

Specimen Collection

Bandages and Binders

Heat and Cold Applications

Client Comfort and Pain Management

Preoperative and Postoperative Care

Surgical Asepsis

Wound Care

End-Of-Life Care