HESI Fundamentals Practice Set 3 A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which of the following interventions should the nurse implement to prevent infection?
a) Thread the IV catheter so that the hub rests at the insertion site
b) Shave excess hair from around the insertion site
c) Cleanse the site with hydrogen peroxide before IV catheter insertion
d) Palpate the site carefully just before inserting the IV catheter - ANSWER
A Inserting the catheter up to the hub reduces the risk of contaminating along the length of the catheter what can increase the risk for infection at an iv site?What is used to clean the site? - ANSWER -shaving excess hair around insertion site -palpating the site after cleansing b/c this can introduce micro-organisms -iodine or chlorhexidine to cleanse the agent before insertion 1 / 3
A nurse is caring for a postoperative adult client who refuses to use an incentive spirometer following major abdominal surgery. Which of the following is the nurse's priority action?
a) Request that a respiratory therapist discuss the technique for incentive
spirometry
b) Administer a pain medication to the client
c) Chart the client's refusal to participate in health restorative activities
d) Determine the reasons why the client is refusing the use the incentive
spirometer - ANSWER D *the first action of the nurse should be to use the nursing process and ASSESS the client first A nurse is preparing to administer ampicillin 40mg/kg/day PO divided in equal doses every 6 hours to a toddler who weighs 10 kg. Available is ampicillin oral suspension 125/5 mL. How many mL should the nurse administer per dose? - ANSWER mg x kg/day = X 40 mg x 10 kg = 400 mg 400 / 4 = 100 mg per dose is desired 125 mg / 5 mL = 100 mg / X mL X = 4 A nurse is preparing to administer meperidine (Demerol) 80 mg IM from a 100 mg prefilled syringe. After the injection, which of the following is an appropriate action by the nurse? 2 / 3
a) Return the unused portion to the pharmacy
b) Have another nurse witness the disposal of the excess medication
c) Place the syringe with the unused portion in a locked medication drawer
d)Discard the unused medication in the sharps container - ANSWER B meperidine is a controlled substance -the remaining medication should be wasted with the witness of another nurse A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? SATA
a) Place the client in a negative pressure room
- wear gloves when assisting the client with oral care
- limit each visitor to 2 hr increments
- wear a surgical mask when providing care
e) Use antimicrobial sanitizer for hand hygiene - ANSWER A, B, E
-limiting visitors is not necessary -N95 respirator mask should be worn to meet the requirements of airborne precautions A charge nurse is discussing the responsibility of nurses carig for clients who have
- difficile. Which of the following information should the nurse include in the
teaching?
a) Assign the client to a room with a negative air-flow system
b) Use alcohol-based hand sanitizer when leaving the clients room
- clean contaminated surfaces in the clients room with a phenol solution
- / 3