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Advanced Nursing Skills Exam 1 Questions with actual answers.
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Advanced Nursing Skills Exam 1Questions with actual answers.
*What is the order for mixing rapid acting/long acting insulin from two vials? ANS - Cloudy-
clear-clear-cloudy
*Where should the nurse administer a subcutaneous insulin injection? ANS - Abdomen
*What site best absorbs insulin? ANS - Abdomen (followed by arm, thighs, and buttocks.
*Chest tube insertion for hemothorax is between the ___ and ___ ICS ANS - 4-6
*Chest tube insertion for pneumothorax goes into the ____or ___ICS ANS - 2nd or 3rd
*Empynema ANS - pus from an infection (pneumonia)
*It is important for the nurse to obtain informed consent from the patient before
______________. ANS - administering pain medication (Opioids)
*If needing to take longer to set up a new chest tube system the nurse
should______________. ANS - Place the end of the chest tube in sterile water.
*In the instance that the chest tube becomes disconnected the nurse knows to: ANS -
Quickly cover insertion site with occlusive vaseline gauze during the PEAK of INSPIRATION.
*The nurse know to ______________ if she notices changes in drainage greater than
________mL/hr. ANS - Notify MD of changes >100 mL/hr
*The nurse knows to encourage the patient to ______________, and ______________ as
the chest tube is being pulled out. ANS - Take a deep breath and hold, and tape on three
sides (when the chest tube___________________)
*True/False The nurse should always be sure to take the velcro ties off before she puts the
new one on. ANS - FALSE she only does this if there is an assistant present to hold
tracheostomy tube in place until new ties are firmly tied down.
*True/False: If the nurse notices a change in the patient with a chest tube's condition she
should notify the MD. ANS - True
*Correct incision site is made between ____________________ and the tube is inserted
directly into the trachea- just below the larynx. ANS - second and third tracheal rings
, *You must take no longer than _______ when cleaning a trach ANS - 15 sec
*No fluctuations in water-seal chamber indicates: ANS - Lung re-expansion; kink or clot in
tubing indicates:
*True/False The nurse knows not to recap any needle ANS - True Box 31-23
*True/False The nurse should maintain a sharps injury log that includes: type and brand of
device involved in the incident; location of the incident; description of the incident; and
privacy of the employees who have had sharps injuries to prevent needlestick injury ANS -
True
*The nurse knows to ______________ in order to allow the patient to speak. ANS - place a
speaking valve in the patient's trach and DEFLATE the cuff
*The nurse knows that when she completes trach care, she must always have the patient in
________________ position. ANS - Semi-fowlers
*A tracheostomy allows for comfort and mobility over a/an___________. ANS -
Endotracheal tube
*The nurse knows that if a tracheostomy tube becomes dislodged she needs to__________.
ANS - Attempt to replace it (Deb)
*An endotracheal tube or tracheostomy tube is connected by ______________ to the
ventilator. ANS - oxygen tubing
*The nurse must ______________ BEFORE initiating ventilation. ANS - ensure that the
healthcare team is aware of the patient's advance directives and consult with family
members
*The nurse knows that an oropharyngeal airway should be used in _________________
patients ANS - Unconscious (because they are likely to trigger gagging, vomiting, or
laryngospasms in responsive patient with airway intact reflexes.)
*The nurse knows that oropharyngeal airways are likely to trigger _________,________, or
____________ in responsive patient's with intact reflexes. ANS - gagging, vomiting, or
laryngospasms
*Oropharyngeal airways ANS - C-shaped, hard plastic devices available in infant, pediatric,
and adult sizes
*Nasopharyngeal airway are contraindicated in patients with ANS - In patients with a jaw
fracture or skull fracture this in contraindicated.
*The tip rests on the hypo-pharynx ANS - Nasopharyngeal airway
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