GCC 426 - 450

An infant is in need of intravenous access. The nurse makes an observation about scalp veins. Which statement indicates the nurse is knowledgeable about this type of venous access?

• The vein has to be cannulated in a downward fashion toward the neck.
• These veins are good to have, but I can’t give anything very fast through them.
• I remember that you are not supposed to use a tourniquet on these veins.
• Once I see a flash of blood, I need to advance the needle and cannula 1/8 inch.
• -

Answer explanation

Option 1: The vein has to be cannulated in a downward fashion toward the neck.

Option 2: These veins are good to have, but I can’t give anything very fast through them.

Option 3: I remember that you are not supposed to use a tourniquet on these veins.

Option 4: Once I see a flash of blood, I need to advance the needle and cannula 1/8 inch.

Option 5: -

Correct Option: Option 2 – These veins are good to have, but I can’t give anything very fast through them.

Explanation: It is difficult to administer increased amounts of intravenous fluids or medications through a scalp vein. Blood flow in scalp veins goes in either direction. The vein is “milked” to determine which way the flow goes in that particular vein. Once the direction has been determined, the needle is inserted in that direction. A rubber band is used as a tourniquet to distend the vein. The cannula is advanced once a flash of blood is noted.

The nurse leaves a patient who is elderly and confused to find someone to assist with transferring the patient to bed. While the nurse is gone, the patient falls and hurts herself. The nurse is at fault because she hasn't:

• Properly educated the patient about safety measures.
• Restrained the patient.
• Documented that she left the patient.
• Arranged for continual care of the patient.
• -

Answer explanation

Option 1: Properly educated the patient about safety measures.

Option 2: Restrained the patient.

Option 3: Documented that she left the patient.

Option 4: Arranged for continual care of the patient.

Option 5: -

Correct Option: Option 4 – Arranged for continual care of the patient.

Explanation: By leaving the patient, the nurse is at fault for abandonment. The better courses of action are to turn on the call bell or elicit help on the way to the patient’s room. Options A and C are incorrect because neither excuses the nurse from her responsibility for ensuring the patient’s safety. Option B is incorrect because restraints are only to be used as a last resort, when all other alternatives for ensuring patient safety have been tried and have failed; moreover, restraints won’t ensure the patient’s safety.

Damage to the VII cranial nerve results in:

• Facial pain
• Absence of ability to smell
• Absence of eye movement
• Tinnitus
• -

Answer explanation

Option 1: Facial pain

Option 2: Absence of ability to smell

Option 3: Absence of eye movement

Option 4: Tinnitus

Option 5: -

Correct Option: Option 1 – Facial pain

Explanation: The facial nerve is cranial nerve VII. If damage occurs, the client will experience facial pain. Answer B is incorrect because the olfactory nerve is responsible for smell. Answer D is incorrect because the auditory nerve is responsible for hearing loss and tinnitus. Answer C is incorrect because eye movement is controlled by the Trochlear or C IV.

Which patient has the highest risk of developing anemia?

• A patient with a colostomy following colon resection
• A patient with gastroesophageal reflux disease (GERD)
• A patient who has had a gastrectomy
• A patient with frequent bouts of dumping syndrome
• -

Answer explanation

Option 1: A patient with a colostomy following colon resection

Option 2: A patient with gastroesophageal reflux disease (GERD)

Option 3: A patient who has had a gastrectomy

Option 4: A patient with frequent bouts of dumping syndrome

Option 5: -

Correct Option: Option 3 – A patient who has had a gastrectomy

Explanation: Lack of intrinsic factor following gastrectomy could cause pernicious anemia as the result of the patient’s inability to absorb Vitamin B12. The presence of a colostomy (Option A), GERD (Option B), or dumping syndrome (Option D) wouldn’t place a patient at risk for developing anemia.

Perineal pain in the absence of any observable cause suggests which condition?

• Endometriosis
• Internal hemorrhoids
• Prostatitis
• Renal calculi
• -

Answer explanation

Option 1: Endometriosis

Option 2: Internal hemorrhoids

Option 3: Prostatitis

Option 4: Renal calculi

Option 5: -

Correct Option: Option 3 – Prostatitis

Explanation: Prostatitis can cause prostate pain, which is felt as perineal pain or discomfort. Endometriosis (Option A) can cause pain low in the abdomen, deep in the pelvis, or in the rectal or sacrococcygeal area, depending on the location of the ectopic tissue. Hemorrhoids (Option B) cause rectal pain and pressure. Renal calculi (Option D) typically produce flank pain.

A client with an above-the-knee amputation is being taught methods to prevent hip-flexion deformities. Which instruction should be given to the client?

• Lie supine with the head elevated on two pillows.
• Lie prone every 4 hours during the day for 30 minutes.
• Lie on your side with your head elevated.
• Lie flat during the day.
• -

Answer explanation

Option 1: Lie supine with the head elevated on two pillows.

Option 2: Lie prone every 4 hours during the day for 30 minutes.

Option 3: Lie on your side with your head elevated.

Option 4: Lie flat during the day.

Option 5: -

Correct Option: Option 2 – Lie prone every 4 hours during the day for 30 minutes.

Explanation: To prevent hip-flexion deformities, the client should be instructed to lie prone every 4 hours for 30 minutes during the day. This will force the leg to extend to 0 and prevent the contracture. Answer A, C, and D are incorrect because lying on his back or side, or flat will not help.

A client who is being discharged home will be giving his own enoxaparin sodium (Lovenox) subcutaneously. Which statement by the client indicates the need for further education?

• I remember that I need to hold the needle at a 45 degree angle.
• I know to pinch the skin up for the injection.
• I will not pull back on the plunger before injecting the medicine.
• I am going to use the right side of my lower abdomen all the time.
• -

Answer explanation

Option 1: I remember that I need to hold the needle at a 45 degree angle.

Option 2: I know to pinch the skin up for the injection.

Option 3: I will not pull back on the plunger before injecting the medicine.

Option 4: I am going to use the right side of my lower abdomen all the time.

Option 5: -

Correct Option: Option 4 – I am going to use the right side of my lower abdomen all the time.

Explanation: Injection sites should be rotated on the client’s body. When giving subcutaneous injections, the needle should be held at a 45-degree angle. Skin should be pinched around the area of the injection. Heparin should not be aspirated.

A client with cancer develops xerostomia. The nurse can help alleviate the discomfort associated with xerostomia by:

• Offering hard candy
• Administering analgesic medications
• Splinting swollen joints
• Providing saliva substitute
• -

Answer explanation

Option 1: Offering hard candy

Option 2: Administering analgesic medications

Option 3: Splinting swollen joints

Option 4: Providing saliva substitute

Option 5: -

Correct Option: Option 4 – Providing saliva substitute

Explanation: Xerostomia is dry mouth, and offering the client a saliva substitute will help the most. Eating hard candy in answer A can further irritate the mucosa and cut the tongue and lips. Administering an analgesic might not be necessary; thus, answer B is incorrect. Splinting swollen joints, in answer C, is not associated with xerostomia.

Which of the following test should be performed before beginning a prescription of Accutane?

• Check the calcium level
• Perform a pregnancy test
• Monitor apical pulse
• Obtain a creatinine level
• -

Answer explanation

Option 1: Check the calcium level

Option 2: Perform a pregnancy test

Option 3: Monitor apical pulse

Option 4: Obtain a creatinine level

Option 5: -

Correct Option: Option 2 – Perform a pregnancy test

Explanation: Accutane is contraindicated for use by pregnant clients because it causes teratogenic effects. Answers A, C, and D are incorrect because calcium levels, apical pulse, and creatinine levels are not necessary.

The physician writes the following order: Give 20 mL per kg bolus of normal saline over 60 minutes. The client, a child, weighs 32 pounds. What number of drops should be delivered per minute? The tubing has a drip factor of 10.

• 30 drops.
• 50 drops.
• 110 drops.
• 150 drops.
• -

Answer explanation

Option 1: 30 drops.

Option 2: 50 drops.

Option 3: 110 drops.

Option 4: 150 drops.

Option 5: -

Correct Option: Option 2 – 50 drops.

Explanation: This question requires several steps to determine the correct answer. First, determine the proper amount of normal saline to be given. Change the child’s weight to kilograms. Dividing 32 by 2.2 equals 14.54 kilograms, which is rounded to 15 kilograms. Multiplying 15 kilograms by 20 (20 milliliters per kilogram) equals 300 milliliters to be given as the bolus. Divide 300 milliliters by 60 minutes to equal 5. Multiplying 5 times the drip factor of 10 equals 50 drops per minute.