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- The nurse is to perform Leopold's Maneuver on a pregnant patient. What instructions does the nurse give the patient just before the assessment? a. Do not eat the night before the procedure b. Take slow , deep breaths to relieve pain c. Urinate just prior to procedure d. Remain on strict bed rest prior to procedureA nurse is flushing a patient’s implanted port after adminis-tering medications. The nurse observes that the port flushes, but does not have a blood return. What would be the nurse’snext action based on these findings?a. Gently push down on the needle and flush it a second time.b. Stop flushing and remove the needle; notify the primarycare provider.c. Ask the patient to perform a Valsalva maneuver; changethe patient position.d. Close the clamp; wait 3 minutes, try flushing the portagain.A nurse providing care of a patient’s chest drainage systemobserves that the chest tube has become separated from thedrainage device. What would be the first action that shouldbe taken by the nurse in this situation?a. Notify the physician.b. Apply an occlusive dressing on the site.c. Assess the patient for signs of respiratory distress.d. Put on gloves and insert the chest tube in a bottle of sterilesaline.
- A nurse is securing a patient’s endotracheal tube withtape and observes that the tube depth changed during theretaping. Which action would be appropriate related to thisincident?a. Instruct assistant to notify the primary care provider.b. Assess the patient’s vital signs.c. Remove the tape, adjust the depth to ordered depth andreapply the tape.d. No action is required as depth will adjust automatically.A nurse is reconstituting powdered medication in a vial.Which action is a recommended step in this process? a. The nurse draws up the proper amount of powered medica-tion into the syringe. b. The nurse inserts the needle through the rubber stopper ofthe diluent vial.c. The nurse gently agitates the powdered medication vial tomix the powder and diluent completely.d. The nurse draws up the prescribed amount of medicationwhile holding the syringe horizontally at eye level.On the second day postpartum , the nurse palpates the fundus one fingerbreadth below the umbilicus . Which nursing action is appropriate if the fundus is firm? a. Call the physician b. Catheterize the client . c. Document the findings d. Administer Lortab PO
- The nurse on duty is to administer medications to a hospitalized client. Which of the following actions would a nurse be expected to perform when administering a subcutaneous injection correctly? (Select all that apply.) a. Remove the needle cap with the dominant hand, pulling it straight off. b. Inject the needle quickly at an angle of 45 to 90 degrees. c. Grasp and bunch the area surrounding the injection site or spread the skin at the site. d. If blood appears when aspirating withdraw the needle and reinject it at another site. e. If using the outer aspect of the upper arm, place the patient's arm over the chest with the outer area exposed.A nurse is assisting a patient who is 2 days postoperativefrom a cesarean section to sit in a chair. After assisting thepatient to the side of the bed and to stand up, the patient’sknees buckle and she tells the nurse she feels faint. Whatshould the nurse do in this situation?a. Wait a few minutes and then continue the move to the chair.b. Call for assistance and continue the move with the help ofanother nurse.c. Lower the patient back to the side of the bed and pivot herback into bed.d. Have the patient sit down on the bed and dangle her feetbefore moving.The nurse on duty is to administer medications to a hospitalized client. Which of the following actions would a nurse be expected to perform when administering a subcutaneous injection correctly? (Select all that apply.) a. Remove the needle cap with the dominant hand, pulling it straight off. b. Inject the needle quickly at an angle of 45 to 90 degrees. c. Grasp and bunch the area surrounding the injection site or spread the skin at the site. o If blood appears when aspirating withdraw the needle and reinject it at another site. d. If using the outer aspect of the upper arm, place the patient's arm over the chest with the outer area exposed.
- A patient had a surgical procedure that necessitated a thoracicincision. The nurse anticipates that he will have a higherrisk for postoperative complications involving which bodysystem?a. Respiratory systemb. Circulatory systemc. Digestive systemd. Nervous systemA patient comes to the emergency department with abdominal pain. Work-up reveals the presence of a rapidly enlarging abdominal aortic aneurysm. Which of the following actions should the nurse expect? A. The patient will be admitted to the medicine unit for observation and medication. B. The patient will be admitted to the day surgery unit for sclerotherapy. C. The patient will be admitted to the surgical unit and resection will be scheduled. D. The patient will be discharged home to follow-up with his cardiologist in 24 hours.A nurse is palpating the breast of a woman during an assess-ment. Which technique is performed correctly? a. The nurse starts at the tail of Spence and moves in increas-ing smaller circles. b. The nurse uses the palms of the hands to gently compressthe breast tissue against the chest wall.c. The nurse works in a counterclockwise direction andpalpates from the periphery toward the areola.d. The nurse starts at the inner edge of the breast and palpatesup and down the breast.