Catheter-associated urinary tract infections are prevalent in hospital

settings. Only indwelling urinary catheters should be used when appropriate.

Appropriate uses include the following:

 Clients with urinary obstruction or retention, or a need for strict intake and output in
critically ill clients
 Perioperative use for surgical procedures such as urologic surgery or prolonged
surgeries, or when large doses of fluid or diuretics are given during surgery
 During prolonged immobilization when bedrest is essential
 To improve end-of-life comfort
 To facilitate healing of an open perineal or sacral wound in incontinent clients

Inappropriate uses include the following:

 Convenience or replacement for nursing care when the client is elderly, confused,
incontinent, or voids frequently (Options 2, 3, and 4)
 For obtaining a urine culture when the client can follow instructions and void voluntarily
 Postoperatively for prolonged periods when other appropriate indications are not present

Educational objective:
The use of indwelling urinary catheters should be minimized during
hospitalization. Appropriate use includes urinary obstruction or retention,
some perioperative circumstances, required prolonged immobilization, end-of-life comfort,
and facilitating healing of an open perineal or sacral wound. Indwelling urinary catheters
should not be used for convenience or as a substitute for nursing care.

Signs and symptoms of a blood transfusion reaction typically will occur within the first 15
minutes after initiation of the transfusion. These include shortness of breath, chest tightness,
fever, back pain, anxiety, tachycardia, and hypotension.
When a transfusion reaction is suspected, the first step is to stop the infusion (Option 5). An
infusion of normal saline is typically started. It is important that normal saline be administered
through a different port of the CVC using new tubing or at the closest access point to the
client. Flushing the blood in the IV tubing into the client will expose the client to more of the
causative agent and increase complications from the transfusion reaction (Option 2). The HCP
must then be notified (Option 3).
Because the client has shortness of breath and chest tightness, an assessment of breath
sounds is appropriate. Adventitious sounds could indicate bronchospasm or excess fluid in the
lungs (Option 1).
(Option 4) A CVC will not be discontinued due to the transfusion reaction. IV access will be
required for administration of fluids and medications.
Educational objective:
If an adverse blood transfusion reaction is suspected, the first action is to stop the infusion. An
infusion of normal saline through a different port for the CVC is typically started. A client
assessment and notification of the HCP are also required.
Leakage of more than 500 mL of air into a central venous catheter is potentially fatal. An air
embolism in the small pulmonary capillaries obstructs blood circulation. A central venous
catheter leaks air rapidly at 100 mL/sec. This client requires immediate intervention to prevent
further complications (eg, cardiac arrest, death). The nurse should not delay emergency
treatment, not even to stop and contact the HCP or the rapid response team (RRT).
Priority interventions for active or suspected air embolism are as follows:

1. Clamp the catheter to prevent more air from embolizing into the venous circulation.
2. Place the client in Trendelenburg position on the left side, causing any existing air to
rise and become trapped in the right atrium.
3. Administer oxygen if necessary to relieve dyspnea.
4. Notify the HCP or call an RRT to provide further resuscitation measures.
5. Stay with the client to provide reassurance and monitoring as the air trapped in the right
atrium is slowly absorbed into the bloodstream over the course of a few hours.

Educational objective:
Any delay in treatment of an air embolism could prove fatal. There is no time to call the
HCP. Seal off the source of the leak, and ensure stabilization of the air bubble via left lateral
positioning.

The sterility of an opened bottle of sterile saline cannot be guaranteed. Some institutions'
policies permit recapped bottles of solution to be reused within 24 hours of opening, and
some require disposal of the remaining solution. Therefore, the nurse should intervene when
the student uses sterile saline from a bottle that was opened >24 hours ago.
The general steps for preparing the sterile field for a wet-to-damp dressing change include:

1. Perform hand hygiene.

2. Open a sterile gauze package that has a partially sealed edge with ungloved
hands by grasping both sides of the edge, one with each hand, and pull them apart
while being careful not to contaminate the gauze (Option 2).
3. Hold the inverted opened gauze package 6" (15 cm) above the waterproof sterile
field so it does not touch the field, and then drop the gauze dressing onto the sterile
field (Option 1).
4. Place the sterile dressings on the sterile field 2" (5 cm) from the edge; the 1" (2.5 cm)
margin at each edge is considered unsterile because it is in contact with unsterile
surfaces (Option 3).
5. Use sterile NSS from a recapped bottle that was opened <24 hours ago (if policy
permits).

Educational objective:
The general steps for preparing the sterile field for a wet-to-damp dressing change include:

1. Perform hand hygiene.

2. Open a sterile gauze package with ungloved hands.
3. Hold the inverted opened gauze package 6" (15 cm) above the sterile field.
4. Place the sterile gauze dressing more than 1" (2.5 cm) from the edge of the sterile field.
 5. Use sterile NSS from a recapped bottle that was opened <24 hours ago (if policy
permits).

Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) analgesic administered

(orally, IV, or intramuscularly [IM]) for short-term relief of mild to moderate pain. Usage
should not exceed 5 days due to adverse effects (eg, kidney injury, gastrointestinal
ulcers, bleeding). Ketorolac IM should be administered into a large muscle using the Z-
track method to mitigate burning and discomfort. A 1- to 1½-in (2.5- to 3.8-cm) needle is
recommended to inject medication into the proper muscular space in average-weight
individuals.
(Option 1) The amount of analgesic to administer of a variable dose medication should be
based on the client's pain level, level of consciousness, and history of narcotic use. Selecting
a smaller first dose is appropriate if the nurse is unsure of how the client will respond to the
medication. If needed, the larger amount can be given the next time a dose is requested or an
additional one-time dose can be requested from the health care provider if breakthrough pain
occurs (before the next scheduled medication dose is available).
(Option 2) Hydromorphone IV push, given undiluted or diluted with 5 mL of sterile water or
normal saline, should be administered slowly over 2-3 minutes; rapid infusion increases the risk
of opioid-induced adverse reactions (eg, nausea, itching).
(Option 3) Undiluted morphine IV push should be administered slowly over 4-5 minutes; rapid
infusion increases the risk of opioid-induced adverse reactions (eg, hypotension, flushing).
Educational objective:
Ketorolac, a nonsteroidal anti-inflammatory drug, is used for short-term (≤5 days) pain relief due
to risk of bleeding, gastrointestinal ulcers, and kidney injury. Intramuscular (IM) injections (using
Z-track method) should be given deep into a large muscle due to burning and discomfort. A 1-
to 1½-in (2.5- to 3.8-cm) needle is used to reach the proper muscle space.

A client who is quadriplegic will have limited to no functional mobility in his arms and hands and
will therefore be unable to use any device that requires pushing a small button (Options 1, 2,
and 4). Instead, the nurse should provide a call device that requires application of a small
amount of pressure over a large area, as the client will probably need to use the head to
activate the signal (Option 3). Other call devices that this client would probably be able to
activate include those activated by blowing through a tube or moving the eyes.
Educational objective:
A key element of promoting safety when the client is in an acute care setting is to ensure that
there is a method of signaling the staff for assistance at all times. The nurse should ensure that
the type of call device fits the client's capabilities, that the client is able to use it, and that it is
always placed where the client can activate it before the nurse leaves the room.
The nurse is responsible for observing the home health aide periodically during delegated
tasks. The aide should wash the hands prior to gloving and after glove removal (Option
4). Sterile dressing supplies should be opened prior to the dressing change; this should be
done by carefully peeling from the outermost corner of the package to expose the contents
without contaminating the sterile product (Option 1). A contaminated used dressing should be
placed in impervious plastic or a paper bag before disposal in the household trash (Option 2).
(Option 3) Unused sterile supplies should not be saved as it is not possible to ensure their
sterility.
(Option 5) Paper towels are not impervious and infectious waste from the dressing can seep
through and into other items in the trash can.
Educational objective:
In the home care setting, infection control procedures for changing a dressing include washing
the hands before and after gloving, opening sterile supplies carefully to avoid contamination,
and placing old dressings inside a glove or plastic bag before disposal in the household trash.

Enteric-coated drugs have a barrier coating that dissolves at a slower rate (usually in the
small intestine) to protect the stomach from irritant effects. Crushing enteric-coated medications
(eg, ibuprofen) disrupts the barrier coating and may cause stomach irritation. In addition, the
particles from the coating may clog the NG tube, particularly small-bore NG tubes.
Slow-, extended-, or sustained-release drug formulations are designed to dissolve very slowly
within a specific time frame. Crushing these medications alters this property and introduces
the risk of adverse effects from toxic blood levels due to more rapid drug absorption. Therefore,
the nurse should first contact the PHCP for clarification.
(Options 2 and 4) Double- and extra-strength drugs such as sulfamethoxazole and
acetaminophen may be crushed and administered separately through an NG tube as long as
they are not enteric-coated. The nurse should flush the tube with water before and after each
drug administration.
Educational objective:
Crushing an enteric-coated, slow-release, extended-release, or sustained-release drug disrupts
its designed time of release and is contraindicated. The nurse should contact the PHCP for an
alternate prescription if such a drug is prescribed via NG route.
Giving oral medications to infants requires specialized techniques for safe administration. A
plastic, disposable oral syringe can be used for accurate dosing and ease of delivery (Option
4). Oral medication should be administered with the infant in a semi-reclining position, which
is similar to the feeding position (Option 3). This position promotes comfort, prevents
aspiration, and may be better controlled by the nurse if the infant resists the medication. Liquid
medications administered by oral syringe should be directed toward the back and inside of the
infant's cheek (Option 2). The medication should be dispensed slowly in small amounts,
allowing the infant to swallow between squirts to prevent aspiration.
(Option 1) Medications are never mixed in a bottle of infant formula as this can affect the taste
and the infant may then refuse the formula in the future. In addition, if the infant does not
complete the full feed, underdosing will occur.
(Option 5) Pinching the nose shut during medication administration may
cause aspiration. The infant's mouth should be opened by applying gentle pressure to the chin
or cheeks.
Educational objective:
Disposable oral syringes are the preferred tool to administer oral medications to infants. Infants
should be held in a semi-reclining position, and medications should be given slowly in small
amounts directed toward the back and inside of the cheek.

Wound cultures identify microorganisms to aid in prescribing appropriate antibiotics and are
obtained as follows:

1. Perform hand hygiene, and apply clean gloves. Remove the old dressing. Remove and
discard gloves.
2. Perform hand hygiene, and apply sterile gloves. Assess the wound bed. Cleanse the
wound bed and surrounding skin with normal saline (eg, flushing, swabbing with gauze)
to remove drainage and debris (Option 2). Remove and discard gloves.
 3. Perform hand hygiene, and apply clean gloves. Gently swab the wound bed with a
sterile swab, from the wound center toward the outer margin (Options 4 and
5). Avoid contact with skin at the wound edge as it can contaminate the specimen
with skin flora.
4. Place the swab in a sterile specimen container; avoid touching the swab to the outside of
the container.
5. Apply prescribed topical medication (eg, bacitracin) after obtaining cultures to prevent
interference with microorganism identification (Option 1). Apply new dressing.
6. Remove and discard gloves, and perform hand hygiene. Label the specimen, and
document the procedure.

(Option 3) Pooled purulent exudate likely contains skin flora different from the pathogen(s)
responsible for the infection. Microorganisms responsible for infection are most likely found in
viable tissue.
Educational objective:
Wound cultures are used to identify microorganisms and select appropriate antibiotics. The
nurse should assess and clean the wound, swab from the wound center toward the outer
margin, and avoid contamination (eg, hand hygiene, not touching intact skin with swab) to
prevent misidentification of microorganisms.

The recommended rates for an intermittent IV infusion of potassium chloride (KCl) are no
greater than 10 mEq (10 mmol) over 1 hour when infused through a peripheral line and no
greater than 40 mEq/hr (40 mmol/hr) when infused through a central line (follow facility
guidelines and policy). If the nurse were to administer the medication as prescribed, the rate
would exceed the recommended rate of 10 mEq/hr (10 mmol/hr) (ie, 10 mEq [10 mmol] over 30
minutes = 20 mEq/hr [20 mmol/hr]). A too rapid infusion can lead to pain and irritation of the
vein and postinfusion phlebitis. Contacting the health care provider to verify this prescription is
the priority action.
(Option 1) The nurse would assess the IV site for swelling, tenderness, and redness just
before initiating the KCl infusion and every 30 minutes during administration. However, this is
not the priority action.
(Option 2) The nurse would check the most current serum potassium level just before
administering the KCl and may obtain another level following the infusion, if prescribed. This is
not the priority action.
(Option 4) An electronic IV pump should always be used to administer KCl. To administer the
infusion at the recommended rate of 10 mEq/hr (10 mmol/hr), the nurse would set the pump at
100 mL/hr, but this is not the priority action.
Educational objective:
The maximum rate for infusion of IV potassium chloride through a peripheral vein is 10 mEq/hr,
and the maximum rate through a central vein is 40 mEq/hr.

A modified radical mastectomy includes removal of axillary lymph nodes that are involved in
lymphatic drainage of the arm. Any trauma (eg, IV extravasation) to the arm on the operative
side can result in lymphedema, characterized by painful and lengthy swelling, as normal
lymphatic circulation is impaired by scarring. Therefore, starting an IV line in this arm
is contraindicated.
The nurse should insert the IV line into the most distal site of the unaffected side (Option
2). For client safety, it is also important to ensure documentation of the mastectomy history,
place a restricted extremity armband on the affected arm, and place a sign above the client's
bed notifying hospital staff of necessary mastectomy precautions (eg, no blood pressure
measurements, venipuncture, or IV lines) (Options 3 and 4).
In general, venipuncture is contraindicated in upper extremities affected by:

 Weakness
 Paralysis
 Infection
 Arteriovenous fistula or graft (used for hemodialysis)
 Impaired lymphatic drainage (prior mastectomy)

(Option 1) The stylet should be advanced until blood return is seen (approximately ¼ inch). If
advanced fully, the stylet may penetrate the posterior wall of the vein and cause a hematoma.
(Option 5) Keeping the affected arm in a dependent position for a long time can increase
lymphedema. The client should be reminded that raising the limb helps drainage.
Educational objective:
IV line insertion is contraindicated on the operative side of clients with a prior
mastectomy. Additional contraindications for IV line insertion include weakness, paralysis, or
infection of the arm; or presence of an arteriovenous fistula.

An IV infusion of norepinephrine at 8 mcg/min is prescribed for a client in shock. The

concentration of norepinephrine is 4 mg in 250 mL of D5W. For how many milliliters per hour
(mL/hr) should the nurse program the IV pump? Record your answer using a whole number.

Using dimensional analysis, use the following steps to calculate the infusion rate of
norepinephrine in milliliters per hour:
1. Identify the prescribed, available, and required medication information

o Prescribed:8 mcg norepinephrinemin Available:4 mg

norepinephrine250 mL Required:mLhrPrescribed:8 mcg
norepinephrinemin Available:4 mg norepinephrine250 mL Required:mLhr
2. Convert prescription to the infusion rate needed for administration

o Prescription×available data=mL/hrPrescription×available data=mL/hr

o OR

o (mcg norepinephrinemin)(minhr)(mg norepinephrinemcg

norepinephrine)(mLmg norepinephrine)=mL norepinephrinehrmcg
norepinephrineminminhrmg norepinephrinemcg norepinephrinemLmg
norepinephrine=mL norepinephrinehr
 o OR

o ⎛⎝8 mcg norepinephrinemin⎞⎠(60 minhr)⎛⎝mg norepinephrine1000 mcg

norepinephrine⎞⎠⎛⎝250 mL4 mg norepinephrine⎞⎠8 mcg
norepinephrinemin60 minhrmg norepinephrine1000 mcg norepinephrine250 mL4 mg
norepinephrine
=30 mL norepinephrinehr=30 mL norepinephrinehr
Educational objective:
To calculate the infusion rate of norepinephrine, the nurse should first identify the prescribed
dose (eg, 8 mcg/min) and available medication (eg, 4 mg/250 mL) and then convert to volume in
milliliters per hour (eg, 30 mL/hr).

When administering an otic medication to an adult or child age 3 and older, the pinna is
pulled upward and back to straighten the external ear canal (Option 2). For an infant, the
pinna is pulled downward and straight back.
(Option 1) The child should be placed in the prone or supine position with the head turned to
the appropriate side.
(Option 3) Otic medication should be warmed to room temperature if removed from a
refrigerator prior to administration. Holding the bottle in the palm of the hand is an effective
method of warming. Instilling cold drops into the ear can cause a vestibular reaction, resulting
in dizziness and vomiting.
(Option 4) The medication dropper should be held near the entrance to the ear canal without
touching it. This technique allows the drops to fall against the wall of the canal, reducing
discomfort while avoiding contamination of the dropper. After instilling the drops, the child
should remain with the affected ear up for several minutes to allow full coverage of the
medication.
Educational objective:
When administering otic medication to children age 3 and older, the pinna is pulled upward and
back to straighten the ear canal. The child is placed in a prone or supine position with the head
turned to the appropriate side, and the medication is allowed to drop against the wall of the
canal.

Personal protective equipment (PPE) is necessary when a client is on contamination

precautions (eg, droplet, airborne, contact). A gown is not normally required in an airborne
precaution room; however, if contamination is probable (eg, dressing change, contact with
bodily fluids), a gown is necessary. The proper removal of PPE limits self-contamination. The
exact procedure for donning and removing PPE varies with the level of precautions and location
of nursing practice. Gloves should be removed first and promptly after use to prevent
contamination of other items or noncontaminated materials (Option 2).
To remove gloves: Grasp the first glove by its palmar surface and pull off inside out. Next, slide
fingers of the ungloved hand under the second glove at the wrist and peel off over the first
glove. Discard gloves in an infectious waste container.
(Options 1, 3, and 4) Face shield/goggles, gown, and mask/respirator can be removed after
gloves, which are considered the most contaminated piece of PPE.
Educational objective:
The proper removal of personal protective equipment limits self-contamination. Gloves should
be removed first and promptly after use to prevent contamination of other items or
noncontaminated materials.