Exam 2 (NUR 336) | Questions with Verified Answers
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Course
NUR 336
Institution
NUR 336
Exam 2 (NUR 336) | Questions with Verified Answers The doctor has just ordered a central line insertion on one of your clients. Which of the following tasks may be delegated to a NAP? (Select all that apply). a. Assist with positioning the patient during insertion and care. b. Reporting if the pa...
The doctor has just ordered a central line insertion on one of your clients. Which of the
following tasks may be delegated to a NAP? (Select all that apply).
a. Assist with positioning the patient during insertion and care.
b. Reporting if the patient has a fever.
c. Assessing the site for redness or irritation.
d. Reporting to the nurse if the catheter line appears to have been pulled out further
than its original insertion position.
e. Inserting the central line using aseptic technique.
f. Changing the central line dressing.
(The NAP may assist with positioning the patient and making sure they are comfortable
during the procedure. The NAP can also check for fever and if the catheter line as
moved. They cannot insert the catheter or change the central line dressing or assess
the site for infection.)
Which statement might the nurse make to nursing assistive personnel (NAP) when
caring for a patient with a dressed central venous access device (CVAD) site?
A. "Assess the site frequently for signs of inflammation."
B. "Be sure to change the transparent dressing on the site once every 7 days."
C. "Let me know immediately if the patient's dressing becomes damp."
D. "Make sure the patient knows to notify me if the site becomes painful or swollen."
Which action would the nurse take to minimize the patient's risk for infection when
changing the dressing on a CVAD?
A. Use sterile technique throughout the process.
B. Apply a stabilization device if the initial sutures are no longer intact.
C. Apply a mask to the patient during the procedure.
D. Change the transparent dressing every 48 hours.
What is the most important way in which the nurse can reduce the risk for infection in a
patient with a CVAD that has a gauze dressing?
A. Change the dressing every 48 hours.
B. Apply sterile gloves to remove the original dressing.
C. Cleanse the catheter and insertion site with sterile saline.
D. Label the dressing with the date and time of application and the nurse's initials.
,(A gauze dressing on a CVAD should be changed every 48 hours and as needed.
Doing so will reduce the patient's risk for infection. It is not necessary to wear sterile
gloves to remove the soiled dressing. Cleansing the site with sterile saline will not
minimize the patient's risk for infection. Labeling the dressing will not minimize the
patient's risk for infection.)
What will the nurse do after removing the soiled dressing from a patient's CVAD device?
A. Cleanse the site with soap and water.
B. Use 2% chlorhexidine swabs to cleanse the site.
C. Apply a skin protectant.
D. Remove the catheter stabilization device, if present.
How can the nurse minimize the risk of dislodging the catheter when removing a
dressing?
A. Lower the patient's head during the dressing change.
B. Remove the transparent dressing or tape and gauze in the direction of catheter
insertion.
C. Apply skin protectant while the stabilization device is off.
D. Cleanse the insertion site quickly and gently in concentric circles.
B
A female patient placed in the dorsal recumbent position for the insertion of an
indwelling urinary catheter tells the nurse that she "doesn't feel comfortable in this
position" and that her "back really hurts." What is the nurse's best response?
A. Reassure the patient that the procedure will take only a few minutes.
B. Promise to reposition the patient as soon as the catheter has been inserted.
C. Reposition the patient in a side-lying position, with her upper leg flexed at the knee
and hip.
D. Explain to the patient that the position will allow the catheter insertion to be more
efficient.
Which action(s) would minimize the patient's risk for injury during insertion of an
indwelling urinary catheter?
A. Assessing the patient for allergies related to latex, antiseptic, tape, and/or iodine-
based substances
B. Thoroughly cleansing the patient's perineal area with povidone-iodine solution before
inserting the catheter
C. Performing proper hand hygiene and applying gloves before inserting the catheter
D. Terminating the insertion if the patient reports pain at any time during the procedure
The nurse has completed the initial inspection of the patient's perineum and is preparing
to insert an indwelling urinary catheter. Which action would the nurse complete next?
, A. Begin to establish a sterile field.
B. Open and assemble the urine drainage bag.
C. Remove soiled gloves, and perform hand hygiene.
D. Center the drape over the patient's labia.
Which statement best illustrates the nurse's understanding of the role of nursing
assistive personnel (NAP) when inserting an indwelling urinary catheter in a female
patient?
A. "Please direct the light to better illuminate the patient's perineal area."
B. "You need to be comfortable inserting a catheter in a patient of her size."
C. "See if a size 14-French catheter is big enough."
D. "Find out if the patient has any allergies to latex or iodine."
Which action would the nurse take to reduce the risk for a catheter-associated urinary
tract infection (CAUTI) in a patient with an indwelling urinary catheter?
A. Wear clean gloves when inserting the catheter.
B. Inflate the balloon on the catheter before using it.
C. Use the smallest-size catheter possible.
D. Empty the urine by disconnecting the catheter from the collection bag.
When educating a client about using an incentive spirometer, you should make which of
the following statements? (Select all that apply).
a. Use the incentive spirometer once every 1-2 hours.
b. Use the incentive spirometer 10 times every 1-2 hours.
c. Sit upright when using your incentive spirometer.
d. When using the device, exhale slowly until the piston rises to your goal.
e. After you complete the session, cough and deep breathe a few times to clear the
mucus from your lungs.
When mixing rapid or short acting insulins with intermediate acting insulins, you should:
(Select all that apply).
a. Roll the vial between your hands for suspension.
b. Inject air into the longer-acting insulin first, without touching the medication to the
needle.
c. Draw up the short-acting insulin first.
d. Verify that the correct dosage of insulin has been drawn up with a second nurse.
e. Draw up the longer acting insulin first.
f. Not push any insulin back into the longer acting insulin vial.
The nurse is preparing to mix short- and intermediate-acting insulins to administer to a
patient. Which action best preserves the insulin's effectiveness?
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