1. The correct tubing change time frame for primary tubing is:
a. ☐ Every 24 hours
b. ☐ Every 36 hours
c. ☐ With every bag change
d. ☐ 72 hours
2. A blood transfusion is started on your client. While you are assessing the client, which of the following symptoms indicates a possible hemolytic reaction? Select all that apply.
a. ☐ Low back pain
b. ☐ Tachycardia
c. ☐ Hypotension
d. ☐ Dark urine
e. ☐ Pruritus
f. ☐ Hives
g. ☐ Fever
3. A patient diagnosed with lung cancer is to receive chemotherapy treatments over the next three months. Which IV access methods are appropriate for this patient? Select all that apply.
a. ☐ Peripheral IV access.
b. ☐ Peripherally inserted central catheter (PICC)
c. ☐ Dialysis catheter
d. ☐ Tunneled central venous catheter
e. ☐ Implanted port
f. ☐ Intra-arterial catheter
4. The nurse is preparing to give a patient IV drug therapy. What information does the nurse need before administering the drug? Select all that apply?
- ☐ Indications, contraindications, and precautions for IV therapy.
- ☐ Rate of infusion and dosage of the drug.
- ☐ Compatibility with other IV medications.
- ☐ Allergic reactions to medications.
5. While assessing the patient’s IV site, the nurse identifies signs and symptoms of infiltration. What is the first action that the nurse implements for this patient?
- ☐ Document and continue to monitor the IV site.
- ☐ Elevate the extremity on two pillows.
- ☐ Apply a sterile dressing if drainage is noted.
- ☐ Remove the IV access immediately.
6. The nurse is supervising a nursing student who is preparing an IV bag with IV administration tubing. For which action by the student nurse must the nurse intervene?
- ☐ The student squeezes the drip chamber.
- ☐ The sterile cap from the distal end of the tubing is removed.
- ☐ The distal end is attached to a needless connector.
- ☐ The student touches the tubing spike.
7. A patient has a central line inserted in the vena cava. The nurse assesses the patient for which potential complications related to the procedure? Select all that apply.
- ☐ Punctured lung resulting in a hemothorax.
- ☐ Central line-associated bloodstream infection (CLABSI).
- ☐ Peripheral infiltration and phlebitis.
- ☐ Petechiae noted on the chest.
8. Which priority concept is of concern to the nurse when performing infusion therapy?
- ☐ Acid-base imbalance
- ☐ Tissue integrity
- ☐ Fluid and electrolyte balance
- ☐ Perfusion.
9. Yesterday the nurse removed the staples from the patient’s abdominal wound and applied steristrips. This morning the nurse notes wound dehiscence. Define wound dehiscence. Write or type the answer in the space below.
10. Describe a stage four pressure ulcer. Write or type the answer in the space below.
11. The nurse is assessing a wound on a patient’s abdomen. What is the best technique to assess the wound before applying a new dressing? Select all that apply
a. ☐ Assess the wound like a clock face with 12 o’clock towards the head.
b. ☐ Observe the wound for redness, swelling, or drainage.
c. ☐ Read the previous nurse’s notes and follow the same pattern.
d. ☐ Vigorously swab the wound to obtain a specimen for wound culture.
e. ☐ Use a long sterile cotton swab to assess tunneling and undermining.
12. A patient is diagnosed with chronic psoriasis and is prescribed a topical medication. What does the nurse teach the patient about the proper use of this drug? Select all that apply
a. ☐ Apply the paste every night before going to bed.
b. ☐ Apply the drug generously to the lesion and the surrounding skin.
c. ☐ Check for local tissue reaction and do not apply surrounding skin.
d. ☐ Perform hand hygiene before applying the topical medication.
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