Fundamentals of Nursing Practice Quiz 31

Answer: D – Frank bleeding at the insertion site

Explanation: Phlebitis, the inflammation of a vein, can be caused by chemical irritants (I.V. solutions or medications), mechanical irritants (the needle or catheter used during venipuncture or cannulation), or a localized allergic reaction to the needle or catheter, Signs and symptoms of phlebitis include pain or discomfort, edema and heat at the I.V. insertion site, and a red streak going up the arm or leg from the I.V. insertion site.

Answer: D – Ask the patient to demonstrate the procedure

Explanation: Return demonstration provides the most certain evidence for evaluating the effectiveness of patient teaching.

Answer: D – Most tablets designed for oral use, except for extended-duration compounds

Explanation: Most tablets designed for oral use, except for extended-duration compounds can be administered via gastrostomy tube, Capsules, enteric-coated tablets, and most extended duration or sustained release products should not be dissolved for use in a gastrostomy tube. They are pharmaceutically manufactured in these forms for valid reasons, and altering them destroys their purpose. The nurse should seek an alternate physician’s order when an ordered medication is inappropriate for delivery by tube.

Answer: D – Allergy

Explanation: A drug-allergy is an adverse reaction resulting from an immunologic response following a previous sensitizing exposure to the drug. The reaction can range from a rash or hives to anaphylactic shock.

Answer: D – Order a hemoglobin and hematocrit count 1 hour after the arteriography

Explanation: A hemoglobin and hematocrit count would be ordered by the physician if bleeding were suspected, The other answers are appropriate nursing interventions for a patient who has undergone femoral arteriography.

Answer: A – Is a protective response to clear the respiratory tract of irritants

Explanation: Coughing, a protective response that clears the respiratory tract of irritants, usually is involuntary, However, it can be voluntary as when a patient is taught to perform coughing exercises, An antitussive drug inhibits coughing, Splinting the abdomen supports the abdominal muscles when a patient coughs.

Answer: C – Provide additional bedclothes

Explanation: In an infected patient, shivering results from the body’s attempt to increase heat production and the production of neutrophils and phagocytic action through increased skeletal muscle tension and contractions. Initial vasoconstriction may cause skin to feel cold to the touch. Applying additional bed clothes helps to equalize the body temperature and stop the chills. Attempts to cool the body result in further shivering, increased metabolism, and thus increased heat production.

Answer: D – Completed a master’s degree in the prescribed clinical area and is a registered professional nurse.

Explanation: A clinical nurse specialist must have completed a master’s degree in a clinical specialty and be a registered professional nurse.

Answer: D – Inhibit the growth of microorganisms

Explanation: Microorganisms usually do not grow in an acidic environment.

Answer: D – Bile obstruction

Explanation: Bile colors the stool brown. Any inflammation or obstruction that impairs bile flow will affect the stool pigment, yielding light, clay-colored stool, Upper GI bleeding results in black or tarry stool, Constipation is characterized by small, hard masses, Many medications and foods will discolor stool – for example, drugs containing iron turn stool black.; beets turn stool red.