ATI NUR 125 Exam 4

Correct Answer: "I will replace any IV catheter when I suspect contamination during insertion."

Explanation:

Infection prevention in IV therapy is critical to avoid complications such as IV-associated infections or phlebitis. Replacing an IV catheter when contamination is suspected, especially during insertion, is essential for ensuring that the IV site remains free from infection. It is important to maintain sterile technique during all aspects of IV insertion, and if there is any suspicion of contamination (such as touching the catheter with a non-sterile surface or introducing pathogens), replacing the catheter immediately is the safest course of action.

Why the Other Choices Are Incorrect:

"I will leave the IV catheter in place after the client completes the course of IV antibiotics":

This statement is incorrect because IV catheters should be removed as soon as they are no longer necessary, particularly when the course of therapy is complete. Leaving an unnecessary catheter in place increases the risk of infection and other complications, such as thrombophlebitis.

"As long as I am working with the same client, I can use the same IV catheter for my second insertion attempt":

This is incorrect because once an IV catheter has been used for an insertion attempt and is removed, it is considered contaminated and should not be reused. Reattempting insertion with the same catheter can introduce pathogens and increase the risk of infection.

"If my client needs to use the restroom, it would be safer to disconnect his IV infusion as long as I clean the injection port thoroughly with an antiseptic swab":

Disconnecting the IV infusion is not recommended unless absolutely necessary. Disconnecting and reconnecting an IV increases the risk of introducing pathogens into the system. It is safer to leave the IV infusion connected and ask the client to use a bedpan or assist with other alternatives to avoid disconnecting the infusion.

Summary:

To prevent IV infections, the nurse should replace any IV catheter if contamination is suspected during insertion. Other strategies include removing unnecessary catheters after therapy is complete, not reusing catheters for multiple attempts, and avoiding disconnecting an IV infusion unless absolutely necessary.

Correct Answer: the MMR and Varivax today and the DTaP and IPV in 1 week 

Explanation:

Both the MMR (Measles, Mumps, Rubella) and Varivax (Varicella) vaccines are live vaccines, and although it's generally fine to administer multiple vaccines during the same visit, live vaccines are often recommended to be given on the same day if they are part of the same schedule. This helps avoid any potential issues with the immune system’s response to these live vaccines if given too close together. Therefore, MMR and Varivax can safely be administered on the same day. The DTaP (Diphtheria, Tetanus, and Pertussis) and IPV (Inactivated Polio Vaccine) are inactivated vaccines and are also safe to be administered together. However, if the parents prefer to spread the vaccinations out, it is appropriate to administer these two vaccines 1 week later.

Why the Other Choices Are Incorrect:

the DTaP and Varivax today and the MMR and IPV in 1 week

This is incorrect because Varivax (a live vaccine) and DTaP (an inactivated vaccine) do not have the same immunization properties, and administering them together may result in a less efficient immune response for the live vaccine (Varivax). It’s better to administer MMR and Varivax together as both are live vaccines.

 the IPV and MMR today and the Varivax and DTaP in 1 week

This is not ideal because IPV (inactivated vaccine) and MMR (live vaccine) can be given together, but it is better to administer the live vaccines (MMR and Varivax) on the same day for optimal immune response. Splitting the vaccines into these groups might delay the protection against Varicella.

the MMR and DTaP today and the Varivax and IPV in 1 week

This is not the best option because DTaP and MMR can be given together, but MMR and Varivax are both live vaccines, and they should ideally be given on the same day, so the child receives full protection against all the diseases at once.

Summary:

The best option for the child is to administer the MMR and Varivax vaccines today, as these are live vaccines that can be safely given together. Then, the DTaP and IPV vaccines can be administered in 1 week. This ensures that the vaccines are given at the appropriate time while accommodating the parents’ request to spread out the vaccinations.

Correct Answer:Ampule

Explanation

Ampule:

An ampule is a sealed glass container that is typically used to store single doses of injectable medications in a liquid form. The neck of the ampule is rescored to facilitate easy snapping open. Once the ampule is snapped open, a filter needle must be used to withdraw the medication to prevent any glass particles from being aspirated into the syringe, as the glass neck can break off during opening. Ampules typically hold 1 to 10 mL or more of medication and are often used for sterile solutions.

Why the Other Options Are Incorrect:

 Vial:

A vial is a small container typically made of glass or plastic, designed to hold multiple doses of medication. Unlike an ampule, a vial can be opened and closed using a rubber stopper and does not require snapping open. Vials can contain either liquids or powders and may be used for multiple doses. A vial does not need a filter needle because it has a rubber stopper, which is typically pierced with a needle for withdrawal.

Prefilled syringe:

A prefilled syringe contains medication already loaded into a syringe, ready for injection. These syringes are generally for single-dose use and do not require the use of a filter needle since the medication is already prepared for injection. Prefilled syringes are convenient for ease of use, but they are not in the form of an ampule.

Cartridge:

A cartridge is a container that holds medication and is designed to fit into a syringe holder. Cartridges are often used for insulin or injectable biologics and are not typically snapped open like an ampule. Cartridges are not glass containers that require the use of a filter needle.

Summary

The correct answer is ampule, which is a glass container with a constricted neck that needs to be snapped off to access the medication. A filter needle is required when withdrawing medication from an ampule to avoid drawing in glass particles. This is distinct from other types of containers like vials, prefilled syringes, or cartridges, which have different mechanisms for accessing the medication.

Correct Answer: "I will insert the needle into the client's skin at an angle of 10 to 30 degrees with the bevel up."

Explanation:

When inserting an IV catheter, the needle should be inserted at a low angle of 10 to 30 degrees with the bevel up to ensure proper access to the vein. This angle allows the needle to enter the vein at an optimal angle, reducing the risk of damaging the vein and improving the ease of catheter insertion. The bevel should always be facing upward to avoid puncturing the vein in the wrong direction.

Why the Other Choices Are Incorrect:

"I will thread the needle all the way into the vein until the hub rests against the insertion site after I see a flashback of blood."

After seeing the flashback of blood, the nurse should advance the catheter into the vein, not the needle. The needle is withdrawn after the catheter is placed, and the catheter should be threaded into the vein, not the needle itself. Pushing the needle all the way into the vein can cause injury to the vein and is incorrect practice.

 "I will apply pressure approximately 1.2 inches below the insertion site prior to removing the needle."

This statement is incorrect because the nurse should apply pressure above the insertion site, not below, to prevent blood from leaking out when the needle is removed. Pressure should be applied above the site to maintain vessel patency and reduce the risk of hematoma formation.

"I will choose a vein in the antecubital fossa for IV insertion due to its size and easily accessible location."

While veins in the antecubital fossa (elbow area) may be large and accessible, they are generally avoided for routine IV insertion due to the risk of irritation, discomfort, and potential complications, such as accidental dislodgement. Peripheral veins in the forearm or hand are preferred for most patients unless the antecubital fossa is the only available site.

Summary:

The correct technique for IV insertion includes inserting the needle at an angle of 10 to 30 degrees with the bevel up to ensure proper access to the vein. Other practices, such as advancing the needle too far into the vein, applying pressure incorrectly, or selecting the antecubital fossa without considering potential complications, are not recommended.

Correct Answers:

Urticaria

Blood pressure at 1630

Report of dysphagia

Explanation:

The client is showing signs of a potential anaphylactic reaction, and the following findings require immediate follow-up:

Urticaria:

Urticaria (hives) is a common symptom of an allergic reaction. The appearance of urticaria, especially when accompanied by other symptoms like difficulty swallowing and wheezing, suggests that the client may be experiencing an allergic reaction to the antibiotic (cefazolin). Immediate intervention is required to assess the severity of the reaction and to administer appropriate treatment (such as antihistamines or epinephrine).

Blood pressure at 1630:

The client's blood pressure at 1630 is significantly low (78/52 mm Hg). Hypotension in this context could be indicative of anaphylactic shock, a severe and life-threatening allergic reaction. Immediate follow-up is necessary to address potential anaphylaxis and support the client's circulatory status (through fluids, medications, and possible use of vasopressors).

Report of dysphagia:

The difficulty swallowing (dysphagia) combined with a lump in the throat sensation is a concerning symptom, as it suggests airway compromise, which is characteristic of anaphylaxis. If the airway becomes obstructed, it could lead to respiratory distress and cardiac arrest. Immediate follow-up is essential to assess the client's airway and intervene with appropriate measures (e.g., epinephrine).

Why the Other Findings Are Less Urgent:

Breath sounds at 1600:

At 1600, the client has clear breath sounds. This is a normal finding and does not require urgent follow-up. The wheezing that occurs at 1630 is a more concerning finding.

Temperature:

The slight elevation in temperature (37.5°C / 99.5°F at 1630) is not immediately concerning in this case, especially considering that the client recently received an antibiotic. A mild fever is not unusual after antibiotic administration but should be monitored. However, it does not require immediate follow-up compared to other more urgent symptoms like anaphylaxis.

Summary:

The findings that require immediate follow-up are urticaria, low blood pressure, and dysphagia, as they are indicative of a potential anaphylactic reaction. These symptoms suggest the need for urgent intervention to prevent further complications such as airway compromise and shock.

Correct Answer: Use a 90-degree angle for the injection and assess the site for landmarks before administering.

Explanation:

When administering an intramuscular (IM) injection, it is important to use the correct angle, which is typically 90 degrees to the skin. This allows the needle to properly penetrate the muscle layer, ensuring the medication is delivered into the muscle tissue. Additionally, the nurse should assess the site to identify the landmarks (e.g., the deltoid, vastus lateralis, or ventrogluteal muscles) and avoid nerves, blood vessels, or bones to reduce the risk of injury. Before injection, the nurse should locate the appropriate anatomical landmarks (e.g., the greater trochanter and iliac crest for the ventrogluteal site) to ensure the needle is inserted into the muscle rather than fatty tissue or a blood vessel. This step is crucial to avoid complications such as nerve damage or accidental injection into the wrong tissue.

Why the Other Options Are Incorrect:

Inject the medication at a 45-degree angle to avoid injury:

45-degree angle is generally used for subcutaneous injections, not intramuscular (IM) injections. IM injections require a 90-degree angle to ensure the medication is delivered into the muscle and not the subcutaneous layer.

 Aspirate after the injection to check for blood return:

The practice of aspirating the syringe after needle insertion (to check for blood return) was previously recommended for IM injections to verify that the needle was not placed in a blood vessel. However, current guidelines no longer recommend aspirating during IM injections because the risk of accidentally hitting a blood vessel is low in most injection sites. Aspirating after the injection is incorrect, as it would delay the administration and introduce unnecessary steps.

Inject the medication quickly without assessing the site for any abnormalities:

Skipping the assessment of the site for abnormalities, landmarks, or potential contraindications (such as scars or infection) increases the risk of complications. The site should always be assessed before administering any injection, ensuring that the proper muscle is chosen and that no contraindications are present.

Summary:

The proper technique for intramuscular (IM) injections involves assessing the site for appropriate landmarks, ensuring the correct 90-degree angle for the injection, and avoiding blood vessels and nerves. Aspiration is no longer required before injecting in most cases, and the injection should not be performed without first ensuring the right anatomical location. These steps minimize the risk of complications and ensure the medication is administered safely and effectively.

Correct Answer: Bronchospasm

Explanation:

An anaphylactic reaction is a severe, life-threatening allergic reaction that can affect multiple systems. It is a medical emergency that requires immediate intervention. The primary concern is airway compromise. Bronchospasm (narrowing of the airways), wheezing, and difficulty breathing are hallmark symptoms of this reaction. The nurse must prioritize treating these symptoms by administering epinephrine, which can help alleviate bronchospasm and open the airways.

Why the Other Options Are Incorrect:

Hypotension:

While hypotension can be a result of anaphylactic shock due to vasodilation, it is not the first symptom the nurse will expect to encounter. However, it can develop rapidly after the initial response if the reaction is not addressed.

 Urticaria:

Urticaria (hives) is a common sign of an allergic reaction, but it is not as immediately life-threatening as bronchospasm. The airway must be secured first before addressing skin symptoms.

 Edema:

Edema (swelling), particularly in the throat, is another sign of anaphylaxis but is typically associated with bronchospasm and difficulty breathing. While edema should be managed, it is a secondary concern compared to ensuring the airway is clear and the patient can breathe.

Summary:

When caring for a patient with anaphylaxis, the nurse should first be prepared to manage bronchospasm (difficulty breathing), wheezing, and airway edema. Immediate intervention with epinephrine and securing the airway are top priorities. Other symptoms like hypotension, urticaria, and edema may follow, but they are not as urgent as addressing the compromised airway.

Correct Answer: Smallpox

Explanation

Live virus vaccines contain a weakened (attenuated) form of the virus, which stimulates a strong and long-lasting immune response. The smallpox vaccine is an example of a live virus vaccine and is made using the vaccinia virus, which is related to smallpox but does not cause the disease. This vaccine provides effective immunity against smallpox.

Why the Other Choices Are Incorrect:

Tetanus – This is incorrect because the tetanus vaccine contains a toxoid, which is an inactivated bacterial toxin, not a live virus. Tetanus is caused by Clostridium tetani, a bacterium, not a virus.

Diphtheria – This is incorrect because the diphtheria vaccine is also a toxoid vaccine, meaning it contains an inactivated toxin, not a live virus. Diphtheria is caused by Corynebacterium diphtheriae, a bacterium.

Anthrax – This is incorrect because the anthrax vaccine is made from inactivated bacterial components, not a live virus. Anthrax is caused by Bacillus anthracis, a bacterium, so it does not require a live virus vaccine.

Summary:

Among the listed options, smallpox is the only disease for which a live virus vaccine is used. The smallpox vaccine contains a live, weakened vaccinia virus that helps the immune system build protection against smallpox without causing the disease.

Correct Answer:  Adhesive-backed medicated disks

Explanation:

Adhesive-backed medicated disks, such as transdermal patches, are designed to release medication slowly and continuously over a period of time (hours or days). These patches adhere to the skin and provide controlled, sustained drug delivery, making them ideal for patients who need constant medication levels without the need for repeated dosing.

Why the other options are incorrect: 

Oral tablets: Oral tablets provide medication that is absorbed through the digestive system. They do not offer continuous release and require the patient to take the medication multiple times a day. 

Intravenous infusion: Intravenous infusion delivers medication directly into the bloodstream, but it is usually for immediate or rapid action rather than providing a continuous release over several hours or days. 

Subcutaneous injections: While subcutaneous injections provide medication under the skin, they do not offer sustained, continuous release like adhesive-backed medicated disks. These injections are typically used for immediate dosing and may require multiple administrations.

Summary:

Adhesive-backed medicated disks are designed to provide a steady, continuous release of medication over an extended period. This method is ideal for patients who require consistent drug delivery without frequent dosing, making it more convenient and effective for chronic conditions or long-term therapy.