Review Fundamentals of Nursing Exam #3 South Tampa University

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Fundamentals of Nursing Exam #3 South Tampa University

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Total Questions : 48

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Question 1:

The nurse is caring for a patient with a puncture wound.
How much time must have passed since the patient’s last tetanus toxoid vaccination for the patient to require an additional injection before being discharged from the emergency department?

A. 10 years B. 1 year C. 5 years D. 2 years

Answer and Explanation

Choice A:

Tetanus is an acute infectious disease caused by spores of the bacterium Clostridium tetani.The spores are found everywhere in the environment, particularly in soil, ash, intestinal tracts/feces of animals and humans, and on the surfaces of skin and rusty tools like nails, needles, barbed wire, etc.Anyone can get tetanus, but the disease is particularly common and serious in newborn babies and pregnant women who have not been sufficiently immunized with tetanus-toxoid-containing vaccines.

To ensure that there is adequate antitoxin to neutralize tetanus toxin in the case of a tetanus-prone injury, a booster dose is advised if it has been longer than 10 years since the last tetanus vaccine dose.This is because a single dose of tetanus toxoid produces a rapid anamnestic response. Therefore, if a patient with a puncture wound has not received a tetanus toxoid vaccination in the last 10 years, they would require an additional injection before being discharged from the emergency department.

Choice B:

While it might seem prudent to administer a tetanus toxoid vaccination every year, this is not necessary according to current medical guidelines.Over-vaccination could potentially lead to an increased risk of adverse reactions without providing additional benefits. Therefore, a tetanus toxoid vaccination is not required every year.

Choice C:

A 5-year interval for tetanus toxoid vaccination is not the standard recommendation for general population.However, in some specific cases, such as when indicated for wound management, a tetanus toxoid–containing vaccine might be administered if ≥5 years have elapsed since the previous receipt of any tetanus toxoid–containing vaccine.

Choice D:

A 2-year interval for tetanus toxoid vaccination is not the standard recommendation.The tetanus toxoid vaccination provides protection for a much longer period, and therefore, it is not necessary to administer the vaccine every 2 years.

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Question 2:

The nurse is to administer enoxaparin 40 mg subcutaneously to the patient. Which technique is correct?

A. The nurse aspirates immediately prior to injecting the medication. B. The nurse gently massages the injection site immediately afterward. C. The nurse draws up the medication into a 1-mL syringe with a 32-gauge needle. D. The nurse injects the medication into the soft tissue of the patient’s abdomen.

Answer and Explanation

Choice A:

Aspirating prior to injecting enoxaparin is not recommended. Aspiration was once a common practice to check if a needle had entered a blood vessel. However, research has shown that aspiration is not necessary for subcutaneous injections and may even be harmful. It can cause pain, bruising, and hematoma formation. Additionally, aspirating can increase the risk of needlestick injuries. For these reasons, aspiration is no longer recommended for subcutaneous injections of enoxaparin or other anticoagulants.

Choice B:

Massaging the injection site after administering enoxaparin is not recommended. Massaging can increase the risk of bruising and hematoma formation. It can also cause the medication to be absorbed too quickly, which can increase the risk of bleeding. The best practice is to apply gentle pressure to the injection site with a dry gauze pad for a few seconds after the injection. This will help to prevent bleeding and bruising.

Choice C:

The size of the syringe and needle used to administer enoxaparin is not specified in the question. However, a 1-mL syringe with a 32-gauge needle is a common choice for subcutaneous injections. This size syringe is small enough to be easy to handle, and the 32-gauge needle is thin enough to minimize discomfort.

Choice D:

The abdomen is the preferred site for subcutaneous injections of enoxaparin. The abdomen has a large surface area of soft tissue, which makes it easy to inject the medication. The abdomen is also relatively free of blood vessels and nerves, which reduces the risk of bruising, bleeding, and pain. Other potential injection sites for enoxaparin include the upper arms, thighs, and buttocks. However, the abdomen is generally the preferred site.

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Question 3:

The nurse is to administer 3 mL of medication intramuscularly to an adult patient. Which is the appropriate site for the injection?

A. Dorsal gluteal B. Deltoid C. Vastus lateralis D. Lateral piriformis

Answer and Explanation

Choice A:

The dorsal gluteal site (also known as the dorsogluteal site) was previously a common injection site, but it's now not recommended due to several significant risks: Proximity to the sciatic nerve: The sciatic nerve is the largest nerve in the body, and it runs close to the dorsal gluteal site. Accidental injection into or near the nerve can cause severe pain, nerve damage, and potential paralysis. Difficulty in locating landmarks: The landmarks for the dorsal gluteal site can be difficult to locate accurately, especially in obese patients or those with decreased muscle mass. This increases the risk of injecting into the wrong area. Risk of injury to blood vessels: The dorsal gluteal site also has a higher risk of injury to blood vessels, as several large vessels run through the area.

Choice B:

The deltoid muscle is located in the upper arm and is a common site for intramuscular injections, but it has limitations for larger volumes: Small muscle size: The deltoid muscle is relatively small compared to other IM injection sites. It's generally recommended for smaller volumes of medication (up to 1 mL in adults). Subcutaneous tissue: The deltoid muscle often has a layer of subcutaneous tissue (fat) that can hinder absorption of medication.

Choice C:

The vastus lateralis muscle is the preferred site for intramuscular injections in adults for several reasons: Large muscle size: It's a large, thick muscle that can accommodate larger volumes of medication (up to 5 mL in adults). Easy to locate landmarks: The landmarks for the vastus lateralis are easy to identify, even in obese patients. Few major nerves or blood vessels: It has fewer major nerves or blood vessels in the area, reducing the risk of injury. Pain tolerance: It's generally considered to be a less painful injection site than the deltoid or dorsogluteal sites.

Choice D:

The lateral piriformis muscle is not a recognized or recommended site for intramuscular injections. It's a deep muscle located in the buttocks, and injecting into it would be difficult and potentially dangerous due to its proximity to the sciatic nerve and other important structures.

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Question 4:

The nurse administers a medication to the patient.
Which symptoms indicate that the patient is having an allergic reaction rather than a side effect?

A. The patient correctly demonstrates the exercises and how to use the spirometer. B. The patient explains to the nurse why the exercises and spirometer are important. C. The patient will correctly demonstrate how to use pursed-lip breathing. D. The patient’s pulse oximetry will stay greater than 94% with at least 12 breaths/minute.

Answer and Explanation

Choice A:

None

Choice B:

None

Choice C:

None

Choice D:

None

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Question 5:

Which medication order is written appropriately?

A. Metformin 0.5 g PO B. Methotrexate 15.0 mg PO C. Meropenem 1.0 g IV D. None of the above

Answer and Explanation

Choice A:

Incorrect dosage form: Metformin is typically administered orally as a tablet or liquid suspension, not as a powder for reconstitution (PO). Missing route of administration: The medication order does not specify the route of administration, such as oral (PO), intravenous (IV), or intramuscular (IM). Potential for medication errors: The lack of clarity in the medication order could lead to errors in administration, such as giving the wrong dose or administering the medication by the wrong route.

Choice B:

Incorrect dosage unit: Methotrexate is typically administered in milligrams (mg), not grams (g). Potential for overdose: The order for 15.0 g of methotrexate is a very high dose that could lead to serious adverse effects, including toxicity and death.

Choice C:

Correctly written: The medication order specifies the drug name (meropenem), the dose (1.0 g), the dosage form (IV), and the route of administration (IV). Appropriate dosage range: The dose of 1.0 g of meropenem is within the typical dosage range for this antibiotic. Clear and concise: The medication order is clear, concise, and easy to understand, which helps to reduce the risk of medication errors.

Choice D:

Incorrect: While choices A and B are both incorrect, choice C is a correctly written medication order.

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Question 6:

The nurse is caring for a patient with shallow respirations and diminished breath sounds following abdominal surgery yesterday.

Which are the appropriate actions of the nurse? (Select all that apply.)

A. Teach the patient to splint the incision when coughing to minimize pain. B. Assist the patient to sit up in the chair and ambulate in the hallway. C. Watch the patient use the incentive spirometer and ensure hourly usage. D. Dim the lights, provide warm blankets, and maintain a quiet environment. E. Maintain patient privacy and use therapeutic touch as desired by the patient.

Answer and Explanation

Choice A:

Splinting the incision when coughing helps to minimize pain and discomfort, which can encourage deeper breathing and coughing. This is essential because deep breathing and coughing help to clear secretions from the lungs and prevent atelectasis (collapse of lung tissue). Steps for splinting the incision: Place a pillow or folded towel over the incision site. Instruct the patient to apply gentle pressure to the pillow or towel with their hands when coughing or deep breathing. Encourage the patient to relax their abdominal muscles during coughing and deep breathing exercises.

Choice B:

Sitting up in a chair and ambulating promote lung expansion and help to mobilize secretions. This is because gravity assists in moving secretions from the smaller airways into the larger airways, where they can be more easily coughed up. Additional benefits of sitting up and ambulating: Improved circulation Decreased risk of pneumonia Enhanced recovery from surgery

Choice C:

Using an incentive spirometer hourly helps to increase lung capacity and prevent atelectasis. The device encourages the patient to take slow, deep breaths, which helps to inflate the alveoli (air sacs) in the lungs. Instructions for using an incentive spirometer: Sit upright in a chair or bed. Place the mouthpiece of the spirometer in your mouth and seal your lips around it. Inhale slowly and deeply through the mouthpiece, aiming to raise the piston inside the device as high as possible. Hold your breath for 3-5 seconds. Exhale slowly and completely through the mouthpiece. Repeat the process 10-15 times per hour, or as instructed by your healthcare provider.

Choice D:

Choice E:

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Question 7:

How will the nurse administer a nitroglycerin sublingual tablet to the patient?

A. Have the patient swallow the tablet with a sip of water. B. Crush the tablet and dissolve it in a teaspoon of water. C. Place the tablet in the patient’s mouth next to the cheek. D. Place the tablet under the patient’s tongue.

Answer and Explanation

Choice A:

Incorrect because swallowing the tablet with water would lead to slower absorption and a delayed onset of action. Nitroglycerin is rapidly absorbed through the oral mucosa, and swallowing it would route it through the digestive system, where it would be absorbed more slowly and less effectively. Swallowing the tablet could also increase the risk of side effects, such as headache and flushing, due to the larger amount of the drug that would be absorbed systemically.

Choice B:

Incorrect because crushing the tablet and dissolving it in water would also delay its absorption. This method would require the tablet to dissolve in the water before it could be absorbed through the oral mucosa, which would slow down the onset of action. Crushing the tablet could also damage the medication and make it less effective.

Choice C:

Incorrect because placing the tablet in the patient's mouth next to the cheek would not allow for optimal absorption. The oral mucosa under the tongue is more permeable than the cheek, so placing the tablet under the tongue allows for faster and more efficient absorption. Placing the tablet in the cheek could also increase the risk of the patient accidentally swallowing it.

Choice D:

Correct because placing the tablet under the patient's tongue allows for rapid absorption and a quick onset of action. The sublingual route is the preferred method of administration for nitroglycerin because it allows the medication to bypass the digestive system and be absorbed directly into the bloodstream. This method also allows for the patient to easily remove the tablet if they experience any side effects.

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Question 8:

Which is the priority nursing diagnosis for a patient with shallow respirations following abdominal surgery?

A. Ineffective breathing pattern related to incisional pain and anesthesia. B. Risk for suffocation related to emotional and cognitive stress after surgery. C. Readiness for enhanced comfort related to desire for rest after surgery. D. Deficient diversional activity related to boredom from hospitalization.

Answer and Explanation

Choice A:

Ineffective breathing pattern related to incisional pain and anesthesia is the priority nursing diagnosis for a patient with shallow respirations following abdominal surgery because it addresses the most immediate and life-threatening concern: impaired gas exchange.

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Question 9:

Which assessment finding indicates that the patient is at high risk for development of pulmonary embolism?

A. The patient’s last bowel movement was before surgery, 4 days ago. B. The patient has refused enoxaparin injections after surgery. C. The patient’s platelet count was 45,000/mm^3 this morning. D. The patient required transfusion of two units of packed red blood cells.

Answer and Explanation

Choice A:

A patient's last bowel movement being 4 days ago does not directly increase their risk of pulmonary embolism (PE). While constipation can be a risk factor for deep vein thrombosis (DVT), which can lead to PE, it is not a significant risk factor on its own. It's important to assess for other risk factors for DVT, such as immobility, recent surgery, or a history of blood clots, in conjunction with constipation.

Choice C:

A platelet count of 45,000/mm^3 is low (thrombocytopenia), but it does not directly increase the risk of PE. In fact, a low platelet count can sometimes hinder clot formation. However, it's important to monitor patients with thrombocytopenia for bleeding risks, as they may be more prone to bleeding complications.

Choice D:

While receiving a transfusion of two units of packed red blood cells can increase blood viscosity, which could theoretically slightly increase the risk of PE, it is not a major risk factor. Patients who receive transfusions are often already at an elevated risk of PE due to other underlying conditions or surgeries. It's essential to assess for other risk factors in these patients.

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Question 10:

The post-anesthesia care unit nurse receives a patient from the operating room. Which assessment will the nurse perform first?

A. Check intravenous lines for patency or redness. B. Check nasogastric tube and presence of bowel sounds. C. Check airway, lung sounds, and pulse oximetry. D. Check Foley catheter and surgical fluid intake.

Answer and Explanation

Choice A:

While checking intravenous lines for patency and redness is important, it's not the most immediate priority in the post- anesthesia care unit (PACU). Ensuring airway patency and adequate oxygenation takes precedence over IV assessment. Issues with IV lines can usually be addressed quickly if they arise, whereas compromised airway or breathing can rapidly lead to life- threatening complications.

Choice B:

Assessment of nasogastric tubes and bowel sounds is also important, but it's not as urgent as checking the airway and breathing. Bowel sounds may be absent immediately after surgery due to anesthesia and bowel manipulation, and their presence or absence doesn't necessarily indicate an immediate problem. Similarly, nasogastric tubes can be checked and adjusted as needed after ensuring the patient's airway and breathing are stable.

Choice C:

Checking the airway, lung sounds, and pulse oximetry is the most critical assessment in the PACU because it ensures that the patient is breathing effectively and has adequate oxygen saturation. This assessment addresses the primary ABCs of patient care: Airway: The nurse will assess for any obstructions or potential for obstruction, such as swelling, secretions, or the tongue blocking the airway. They will also ensure proper positioning of the head and neck to maintain airway patency. Breathing: The nurse will listen to lung sounds to evaluate air entry and identify any signs of respiratory distress, such as wheezing, crackles, or decreased breath sounds. They will also monitor respiratory rate and effort. Circulation: Pulse oximetry measures oxygen saturation in the blood, providing a quick and non-invasive assessment of oxygenation status. It's essential to ensure adequate oxygen delivery to tissues and organs. By prioritizing the assessment of airway, lung sounds, and pulse oximetry, the nurse can quickly identify and intervene in any respiratory or oxygenation issues, preventing potentially life-threatening complications.

Choice D:

Checking the Foley catheter and surgical fluid intake is essential for monitoring fluid balance and renal function, but it's not a priority over assessing airway, breathing, and circulation (ABCs). Fluid status can be assessed and managed after ensuring the patient's respiratory and circulatory systems are functioning adequately.

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Fundamentals of Nursing Exam #3 South Tampa University

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