Nurs 311 Exam-Questions with Correct Answers/ Expert verified/ 100% Pass
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Course
NURS 311
Institution
NURS 311
The nurse is capping an existing IV line for intermittent use. Which action by the nurse
follows correct procedure? - ️️cleaning the end cap of the extension tubing with an
antimicrobial swab
Which hospitalized clients are good candidates for capping of an existing intravenous line
for inte...
Nurs 311 Exam -Que stions with Correct Answers/ Expert verified/ 100% Pass The nurse is capping an existing IV line for intermittent use. Which action by the nurse follows correct procedure? - ✔️✔️cleaning the end cap of the extension tubing with an antimicrobial swab Which hospitalized clients are good candidates for capping of an existing intravenous line for intermittent use? Select all that apply. - ✔️✔️Client who is only recei ving fluids at a keep -vein -open rate., Client who needs infusions of an antibiotic only every 12 hours., Client who no longer requires intravenous infusions. The nurse has just flushed a peripheral venous access site and notices fluid leaking from the insertion site. Which action is most appropriate? - ✔️✔️Remove the IV catheter and restart the venous access site in a new location The nurse is capping a client's IV line for intermittent use in preparation for the administration of an antibiotic. After ins pecting the site, what will the nurse do next? - ✔️✔️Close the clamp on the current administration set. The nurse is capping an intravenous (IV) line for intermittent use. Place in order how the nurse will perform these actions. Use all options. - ✔️✔️1)Scrub the needleless connector or end cap on the extension tubing with an antimicrobial swab. 2)Insert the saline flush syringe into the needleless connector or end cap on the extension tubing 3)Aspirate the catheter for positive blood return by gently pull ing back on the syringe. 4)Flush the tubing slowly, over one minute, with a sterile saline filled syringe. 5)Reclamp the extension tubing and loop it near the entry site, securing it with tape. Which situation would warrant the need for the nurse to chang e a client's venous access dressing? - ✔️✔️The skin around the site is wet. The nurse changes a client's peripheral venous access dressing. Which nursing action is correct? - ✔️✔️Press the chlorhexidine applicator against the skin using a back -and-forth motion. Which action by the nurse is most important to ensure the client's sa fety when changing a peripheral venous access device dressing? - ✔️✔️placing the bed in the lowest position before leaving the room The nurse is caring for a client who has been diaphoretic and observes that the dressing on the peripheral venous access si te has become loose and needs changing. Which type of dressing would be best for this client? - ✔️✔️a sterile gauze dressing A nurse is assessing a client's intravenous (IV) site while changing the dressing. Which signs would indicate fluid infiltration i nto the tissue around the IV catheter? Select all that apply. - ✔️✔️Swelling, Pallor, Coolness A nurse is changing a client's peripheral venous access dressing. The nurse finds that the site is bleeding and oozing. Which type of dressing should the nurse use for this client? - ✔️✔️Gauze dressing The nurse is assessing a client's peripheral venous access site and notes redness and inflammation at the site. What is the best action by the nurse at this time? - ✔️✔️Discontinue current IV and relocate to new s ite. The nurse is caring for a client who has a deep wound and whose saline -moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and adheres to the wound bed. Which mod ification is most appropriate? - ✔️✔️Reduce the time interval between dressing changes. The nurse is preparing to perform wound care. Which intervention should be implemented to protect the nurse from injury? - ✔️✔️Raise the bed to elbow height. The nurs e is planning to replace a client's wound dressing. The deep wound bed is to remain moist and requires packing. Which action is appropriate? - ✔️✔️Loosely pack the dampened dressing material to prevent too much pressure on the wound bed. The nurse is chan ging the dressing on a client's surgical wound and notices that part of the dressing is sticking to the underlying skin. What is the recommended nursing intervention in this situation? - ✔️✔️Use small amounts of sterile saline to help loosen and remove the dressing. When removing a client's surgical wound dressing, the nurse notes that there is wound separation and rupture. What is the term for this wound complication? - ✔️✔️Dehiscence. The nurse assesses the surgical dressing of a client who has just arr ived from the post -
anesthesia care unit (PACU) and observes the dressing has a moderate area of serous drainage on it. What is the best action by the nurse? - ✔️✔️Reinforce the dressing and assess site frequently Rationale:Because bleeding is expected dur ing the first 12 to 24 hours after surgery, the best action by the nurse is to reinforce the dressing and assess the site frequently. The nurse is changing the dressing of a client whose skin has been irritated by the frequent removal of adhesive tape that holds the dressing in place. Which would be a recommended nursing intervention? - ✔️✔️Use Montgomery straps instead of adhesive tape to hold the dressing in place. Montgomery straps, non -allergenic tape, or dressing ties, instead of adhesive tape, to hold the dressing in place. A skin barrier could also be used on the skin around the wound (not on the wound itself). The nurse is removi ng the dressing from an abdominal surgical wound during wound care and notices that the wound edges are not intact, there are multiple staples on the dressing, and the surrounding tissue is red with purulent drainage. The chart reports that the incision was clean and dry with the approximated edges and staples intact upon the last assessment. What would be the first recommended nursing intervention in this situation? - ✔️✔️Assess for pain, shortness of breath, and abdominal pressure. The nurse has finished cleaning a client's surgical wound. What would be the nurse's next action in this procedure? - ✔️✔️Pat the wound dry with a sterile gauze sponge. The nurse is changing the dressing on a client's surgical wound. After the old dressing is removed, the nurs e notices that the client's skin is red and blistered where the dressing had
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