Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has a prescription for a peripheral IV catheter.
After puncturing the skin with the vascular access device and noting a blood return in the flashback chamber, which of the following actions should the nurse perform next?
A. Flush the catheter with saline
Choice A is wrong because flushing the catheter with saline should be done after securing the catheter to the skin with a transparent dressing and attaching a primed piece of extension tubing to the catheter.
B. Retract the stylet
Choice B is wrong because retracting the stylet should be done after advancing the catheter into the vein and releasing the tourniquet from the client’s arm.
C. Release the tourniquet
Choice C is wrong because releasing the tourniquet should be done after advancing the catheter into the vein and before retracting the stylet.
D. Advance the catheter into the vein
This is because after puncturing the skin and the vein, the nurse needs to advance the catheter into the vein with the finger hub to ensure proper placement and prevent complications such as infiltration or phlebitis.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Comprehensive Predictor 2023 Exit Proctored Exam A. Take the full exam now
Full Explanation
This is because after puncturing the skin and the vein, the nurse needs to advance the catheter into the vein with the finger hub to ensure proper placement and prevent complications such as infiltration or phlebitis.
Choice A is wrong because flushing the catheter with saline should be done after securing the catheter to the skin with a transparent dressing and attaching a primed piece of extension tubing to the catheter.
Choice B is wrong because retracting the stylet should be done after advancing the catheter into the vein and releasing the tourniquet from the client’s arm.
Choice C is wrong because releasing the tourniquet should be done after advancing the catheter into the vein and before retracting the stylet.
Similar Questions
A nurse is caring for a child who has cystic fibrosis and requires postural drainage.
Which of the following actions should the nurse take?
A. Hold hand flat to perform percussions on the child.
because the nurse should not hold the hand flat to perform percussions on the child. Percussions are rhythmic clapping on the chest wall to loosen the mucus. The nurse should use a cupped hand to create a small air pocket that enhances the vibrations and prevents bruising.
B. Perform the procedure twice each d
wrong because the nurse should not perform the procedure twice a day. The recommended frequency of postural drainage is 3 to 4 times a day, or more if needed, depending on the child’s condition and tolerance.
C. Perform the procedure prior to meals.
This is because postural drainage involves positioning the child in different ways to help drain the mucus from the lungs. If the child has a full stomach, this can cause nausea, vomiting, or aspiration. Therefore, the nurse should perform the procedure before meals or at least 1 hour after meals.
D. Administer a bronchodilator after the procedure
because the nurse should not administer a bronchodilator after the procedure. A bronchodilator is a medication that relaxes and widens the airways, making it easier to breathe. The nurse should administer a bronchodilator before the procedure to enhance the effectiveness of postural drainage.
Full Explanation
The correct answer is choice C. Perform the procedure prior to meals.
This is because postural drainage involves positioning the child in different ways to help drain the mucus from the lungs.
If the child has a full stomach, this can cause nausea, vomiting, or aspiration. Therefore, the nurse should perform the procedure before meals or at least 1 hour after meals.
Choice A is wrong because the nurse should not hold the hand flat to perform percussions on the child.
Percussions are rhythmic clapping on the chest wall to loosen the mucus. The nurse should use a cupped hand to create a small air pocket that enhances the vibrations and prevents bruising.
Choice B is wrong because the nurse should not perform the procedure twice a day. The recommended frequency of postural drainage is 3 to 4 times a day, or more if needed, depending on the child’s condition and tolerance.
Choice D is wrong because the nurse should not administer a bronchodilator after the procedure.
A bronchodilator is a medication that relaxes and widens the airways, making it easier to breathe. The nurse should administer a bronchodilator before the procedure to enhance the effectiveness of postural drainage.
A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy.
The newborn is experiencing neonatal abstinence syndrome.
Which of the following actions should the nurse include in the plan?
A. Swaddle the newborn with his legs extended.
because swaddling the newborn with his legs extended can increase muscle tension and discomfort. Swaddling should be done with the legs flexed and hips abducted to prevent hip dysplasia.
B. Administer naloxone to the newborn
wrong because administering naloxone to the newborn can cause severe withdrawal symptoms and respiratory depression. Naloxone is an opioid antagonist that reverses the effects of opioids, but it is not recommended for newborns with NAS unless they have life-threatening respiratory depression.
C. Maintain eye contact with the newborn during feedings
because maintaining eye contact with the newborn during feedings can overstimulate the newborn and cause agitation. Eye contact should be avoided or limited during feedings for newborns with NAS.
D. Minimize noise in the newborn’s environment
Minimize noise in the newborn’s environment. This is because neonatal abstinence syndrome (NAS) is a condition that affects newborns who are exposed to opioids or other addictive substances in the womb. These substances can cause withdrawal symptoms in the newborns, such as excessive crying, tremors, vomiting, diarrhea, and seizures.
Full Explanation
The correct answer is choice D. Minimize noise in the newborn’s environment.
This is because neonatal abstinence syndrome (NAS) is a condition that affects newborns who are exposed to opioids or other addictive substances in the womb. These substances can cause withdrawal symptoms in the newborns, such as excessive crying, tremors, vomiting, diarrhea, and seizures.
Minimizing noise and other stimuli can help calm the newborn and reduce stress.
Choice A is wrong because swaddling the newborn with his legs extended can increase muscle tension and discomfort. Swaddling should be done with the legs flexed and hips abducted to prevent hip dysplasia.
Choice B is wrong because administering naloxone to the newborn can cause severe withdrawal symptoms and respiratory depression. Naloxone is an opioid antagonist that reverses the effects of opioids, but it is not recommended for newborns with NAS unless they have life-threatening respiratory depression.
Choice C is wrong because maintaining eye contact with the newborn during feedings can overstimulate the newborn and cause agitation. Eye contact should be avoided or limited during feedings for newborns with NAS.
A nurse is providing teaching to the parents of a newborn about newborn genetic screening.
Which of the following statements should the nurse include in the teaching?
A. A nurse will draw blood from your baby’s inner elbow
is wrong because the blood sample is not drawn from the baby’s inner elbow, but from the heel. Choice
B. Your baby will be given 2 ounces of water to drink prior to the test
wrong because the baby does not need to drink water prior to the test, as this could dilute the blood sample and affect the results.
C. This test will be repeated when your baby is 2 months old
wrong because the test does not need to be repeated when the baby is 2 months old, unless there is a positive or inconclusive result from the first test.
D. This test should be performed after your baby is 24 hours old
This test should be performed after your baby is 24 hours old. This is because newborn genetic screening is a set of laboratory tests that detect a set of known genetic diseases that can affect a child’s long-term health or survival. The test is performed on a blood sample obtained from a heel prick when the baby is two or three days old. Performing the test after 24 hours ensures that the baby has had enough time to metabolize certain substances that could interfere with the accuracy of the test.
Full Explanation
The correct answer is choice D. This test should be performed after your baby is 24 hours old. This is because newborn genetic screening is a set of laboratory tests that detect a set of known genetic diseases that can affect a child’s long-term health or survival. The test is performed on a blood sample obtained from a heel prick when the baby is two or three days old. Performing the test after 24 hours ensures that the baby has had enough time to metabolize certain substances that could interfere with the accuracy of the test.
Choice A is wrong because the blood sample is not drawn from the baby’s inner elbow, but from the heel. Choice B is wrong because the baby does not need to drink water prior to the test, as this could dilute the blood sample and affect the results. Choice C is wrong because the test does not need to be repeated when the baby is 2 months old, unless there is a positive or inconclusive result from the first test.
Newborn genetic screening is important for early detection and intervention of certain conditions that can cause serious health problems or disability if left untreated. Parents should be informed about the benefits and limitations of the test, as well as their rights and options regarding consent and confidentiality.