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NUR 2727C Exam 1 Guide With Complete Solution
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NUR 2727C Exam 1 Guide WithComplete Solution
Which action should the nurse take to maintain sterility when performing a
dressing change?
A. put the unopened sterile glove package carefully on the sterile field
B. remove the sterile drape from its package by lifting it by the corners
C. don sterile gloves before opening the package containing the field drape
D. pour irrigation liquid from a height of at least 3 inches above the sterile
container - ANSWER B. remove the sterile drape from its package by lifting it
by the corners
A client is to receive a transfusion of packed red blood cells. Which solution
would the nurse use to prime the blood intravenous tubing?
A. lactated ringer solution
B. 5% dextrose and water
C. 0.9% normal saline
D. 0.45% normal saline - ANSWER C. 0.9% normal saline
Which technique would the nurse use in attempting to glove the second
hand when donning sterile gloves?
A. grasp the finger portion of the second glove and lift; then insert remaining
hand into glove
,B. insert gloved fingers under cuff of second glove and lift glove; then slide
ungloved hand into glove
C. using your gloved hand, grasp the folded edge of the second glove with
two fingers and place glove on nondominant hand
D. don glove on non dominant hand first, then hold the glove away from
body and below waist to slid glove on - ANSWER B. insert gloved fingers
under cuff of second glove and lift glove; then slide ungloved hand into
glove
Which action by the nurse is best when a client who has a hemoglobin of 6
g/dL is refusing blood because of religious reasons?
A. ask the client's family to intervene with the decision
B. remind the client that death is a possibility without transfusion
C. notify the health care provider of the client's refusal of blood products
D. explain that the benefits of blood transfusion may outweigh religious
concerns - ANSWER C. notify the health care provider of the client's refusal
of blood products
A family member of a client who is prescribed a blood transfusion mentions
that blood transfusions are not permitted in their faith. Which action would
the nurse take to handle the situation?
A. wait for the court's order to give blood to the client
B. proceed with the transfusion to save the client's life
C. inform the primary health care provide and not give blood to the client
D. explain to the family member that the client needs this transfusion -
,ANSWER C. inform the primary health care provide and not give blood to the
client
Which technique would the nurse use to maintain surgical asepsis?
A. change the sterile field after sterile water is spilled on it
B. put on sterile gloves before opening a container of sterile saline
C. place a sterile dressing no more than half an inch from the edge of the
sterile field
D. clean the surgical area with a circular motion, moving from the outer edge
toward the center - ANSWER A. change the sterile field after sterile water is
spilled on it
In which order would the nurse complete these steps when administering a
blood transfusion?
1. ascertain that intravenous catheter size is 18 or 20 gauge
2. check primary health care provider's prescription
3. change main line solution to normal saline
4. check client identification before hanging unit of blood
5. obtain vital signs and history of transfusions - ANSWER 2, 5, 1, 3, 4
Which action would the nurse take to prevent venous thrombus formation
after abdominal surgery?
A. keep the client in a catch bed to elevate the knees
B. have the client dangle the legs off the side of the bed
, C. help the client use an incentive spirometer every hour
D. encourage the client to ambulate multiple times daily - ANSWER D.
encourage the client to ambulate multiple times daily
Which action is the nurse's priority when the nurse notices the client
receiving a blood transfusion is having an acute hemolytic reaction?
A. stop the blood transfusion immediately
B. report to the primary health care provider
C. recheck identifying tags and numbers on the client
D. maintain a patent intravenous line with saline solution - ANSWER A. stop
the blood transfusion immediately
The spouse of a comatose client refuses to allow transfusions of whole blood
because they are Jehovah's Witnesses. The client does not have a durable
power of attorney for health care. Which action by the nurse is correct?
A. institute the prescribed blood transfusion because the client's survival
depends on volume replacement
B. clarify the reason why the transfusion is necessary and explain the
implications if there is not transfusion
C. phone the primary health care provider for an administrative prescription
to give the transfusion under these circumstances
D. give the spouse a treatment refusal form to sign and notify the primary
health care provide so legal action can be considered - ANSWER D. give the
spouse a treatment refusal form to sign and notify the primary health care
provide so legal action can be considered
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