NSE22AB Exam Review

A lab analysis of a patient's wound culture indicates that epidermal cells were present in the culture. What is the nurse's next action? Select all that apply.

Document this as a normal finding in the chart

Notify the health care provider of the findings

Repeat the collection of the specimen if ordered

Administer antibiotics according to agency policy and the health care provider's order

Monitor the patient for fever, pain

The nurse prepares to collect a anaerobic specimen from the patient's wound for C & S. After applying hand hygiene and gloves, the nurse aspirates 10 mL of exudate along with small air bubbles from deep within the wound bed. The nurse then attaches a needle to the syringe and injects the exudate into a carbon dioxide tube to be prepared for analysis at the lab. Hand hygiene and disposal of supplies occurs afterwards. Which step by the nurse is incorrect?

The nurse selected the wrong tube; a tube containing medium should have been used

The nurse aspirated too much exudate; the optimal aspiration amount is 2.5 - 5 mL

The nurse did not remove the air bubbles prior to injecting the exudate

A and C

None of the above, the nurse performed the procedure correctly

A patient is to have a feeding tube inserted as indicated by the health care provider's order. Based on the following information, which tube is the most likely insertion choice? The patient was prescribed a short term insertion into a site where the pH is 6, to decrease the risk of aspiration pneumonia and reinstate bowel motility.

Nasointestinal tube

PEJ tube

Orogastric tube

None of the above

At 0700, your patient is receiving Jevity via NG tube at 60 mL/hr. The patient has a test at 1000 where feeds will be held for 2 hours, after which the feeds will be reinstated. Calculate the total amount of intake during your shift from 0700 - 1900.

600 mL

0.06 L

720 mL

1320 mL

At which rate can you safely increase an administered intermittent feeding, assuming it is tolerated?

50 mL daily

30-60 mL q8-12h

50 mL q6h

You cannot increase the rate, only the concentration

A patient with a spinal cord injury at C4 requires the administration of oxygen at 4 L/min. Which method is best, and why?

Face tent, because FiO2 can be 100% which helps prevent hypoxia in the case of neurogenic shock

Mechanical ventilation, because respiratory impairment is likely

Partial non-rebreather mask, because the likelihood of carbon dioxide inspiration is low, promoting better oxygenation

BiPAP therapy, because it can maximize the use of the lungs by providing differing pressures for inspiration and expiration

The symptoms of hypoxia occur in a progressive fashion. Select the order that is correct in terms of hypoxia worsening. 1) Restlessness 2) Pallor 3) Tachycardia 4) Decreased LOC 5) Cyanosis

1, 2, 3, 4, 5

1, 4, 3, 2, 5

5, 2, 3, 4, 1

1, 4, 2, 3, 5

The nurse is preparing to administer ophthalmic drops to the appropriate organ. Which steps indicate that the nurse has administered the medication correctly? Select all that apply

The nurse performs all of the appropriate MAR checks, patient identifications, and rights of medication administration,

The nurse pulls the pinna upwards and back to administer the medication

The nurse pulls the lower eyelid down and administers the medication on the cornea

The tragus is pressed down repeatedly to ensure better adminstration

The tear drainage duct is temporarily blocked after administration by applying pressure

While assessing your patient prior to medication administration, they request an analgesic for their 8/10 rated pain. It is 0800 and your patient has the following medications due today: Humalog sliding scale units SC ac with QID Accuchecks (sliding scale provided in order notes), dalteparin SC 5000 units qhs, acetaminophen 325 mg PO tablet q6h (0600, 1000, 1600, 2200), and 0.5 mg Vicodin tablet PO q12h PRN (last dose administered at 2000 previous day). Which medication will you administer first?

Acetaminophen

Vicodin

Humalog

Dalteparin

To mix insulins for adminstration, the correct steps include the following. Select all that apply.

Aspirate enough air for the rapid acting and inject this into the vial, then remove needle

Obtain the clear (rapid) insulin in the syringe before the cloudy (long) insulin

Verify that the syringe contains the total amount of both doses of insulin

Obtain this syringe

In the unit where you work, you are preparing to administer Fluvirin 0.1 mL IM for 1 dose now to a healthy adult client. Which description is the best administration?

1 mL syringe, 25-27 gauge, 1 to 1.5 inches, deltoid site at 90 degrees

1 mL syringe, 20-25 gauge, 1 to 1.5 inches, ventrogluteal site at 90 degrees

1 mL syringe, 25-27 gauge, 0.38 to 0.63 inches, lower abdominal site at 45 degrees

1 mL syringe, 20-25 gauge, 1 to 1.5 inches, deltoid site at 45 degrees

What constitutes a break in the sterile field? Select all that apply.

Using clean gloves to open the sterile field

Sterile saline splashes onto the field

Placing sterile gloved hands at your side while waiting to begin sterile procedure

The patient sneezes near the sterile field

A contaminated item falls onto the outer 1 inch (2.5 cm) border of the field

Which drainage indicates the beginning of healing from a wound resulting from a THR 8 hours earlier?

Drainage A

Drainage B

Drainage C

Drainage D

Your patient has rung the call bell. Upon entering the room, he says "It feels like something has given way" in reference to his abdominal wound. Upon further inspection, you note that the wound edges have come apart and an organ is beginning to come out. What are your next steps as the nurse? Select all that apply.

Place sterile gauze soaked in sterile saline over the site

Contact the surgeon immediately

Instruct the patient to use a pillow to brace when coughing

Using sterile gloves, push the wound closed and redress according to the health care provider's order

Obtain the patient's vitals every 15 minutes

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