NURSEZONE

4th Floor Florentine Bldg. Bonifacio St. Davao City

2865436
EXAM CODE: SKILLS ENHANCEMENT SERIES
SUBJECT: COMPREHENSIVE EXAM

IV THERAPY
Situation: Mary, the NOD of the emergency room received her endorsement from the night shift. As a nurse, she knows that part of her care
includes carrying out, the doc tor’s order.

1. Doctor Samnillo ordered IV insertion for an IV push. Nurse Mary now prepares the IV kit, and explains the procedure to the patient. In site
selection, Nurse Mary knows that the best site for intravenous insertion is. (Select all that applies)
i. Metacarpal vein ii. Temporal vein iii. Metacarpal arteries
iv. Basillic vein v. Cephalic vein vi. Metatarsal arteries

a. 1,2,4 b. 2,3,4 c. 1,2,4,5 d. 1,2,3,6

2. Nurse Mary now selects a vein for insertion; she knows that the principle of insertion is inserting a vein from:
a. Medial to proximal b. Distal to proximal c. Proximal to distal d. Outer to inner

3. Nurse Mary’s patient has undergone right modified radical mastectomy and has a venous shunt on the right left brachial vein. She is ordered
to insert on IV for an IV push of antibiotics. She knows that she should insert the site as:
a. Anywhere but both upper extremities c. At the left radical and cephalic vein
b. At the left brachial vein d. At the right basillic or cephalic vein

4. Ms. Dora, a post appendectomy patient complained of pain on her insertion site. Upon assessment, you noticed cool clammy swelling site and
pain. You also noticed that the IV drip chamber is not infusing any longer. You should:
a. Stop infusion and tell your supervisor c. Inform the physician and remove the IV
b. Stop the infusion and inform the physician d. Remove the IV and document your action.

5. Complications of IV therapy include all of the following, except:

a. Infiltration b. Phlebitis c. None of the above d. All of the above

6. A mother came into your care carrying a 2 year old child who is severely dehydrated as diagnosed by the physician. IVF was ordered to
recompensate severely fluid loss. A good IV therapist nurse is requested because:
a. The 2 year old child is prone to dislodgement
b. The child’s vein have collapsed and is difficult to insert
c. The child’s vein have protruded and it is movable and difficult to insert
d. The child’s hand has to be restrained and inserted at the same time

7. Upon assessment, Nurse May wants to assess signs and symptoms of phlebitis. As a nurse, she knows that phlebitis is the infection of the IV
site and this should be prevented. Signs and symptoms of phlebitis includes:
a. Cold, clammy swelling skin c. Edema and pain as the insertion site
b. Pain in the insertion site d. Warm, swelling, painful insertion site.

8. The NOD for the night shift carried out the doctor’s order to change the IV site due to infiltration. The previous site was inserted at the left
cephalic vein on the arm area. All of the following sites are sites of insertion, except:
a. Metacarpal vein at the same arm c. Distal cephalic vein on the same arm
b. metacarpal vein on the right arm d. cephalic vein on the same arm.

9. Before intravenous insertion. All but one is the most important nursing intervention.
a. Explain the procedure to the patient c. Double check the signed consent
b. Verify doctor’s order d. Provide privacy

10. Mary now inserted a gauge-18 catheter to a patient who will undergoing blood transfusion, she then hooks one (1) liter of PNSS. Mary
noticed bubbles of air on the IV tubing. Which of the following interventions is the best way of removing the air bubbles on the tube?
a. Tap the IV tubing until air reaches the drip chamber
b. Prime the IV tubing before connecting it to the IV catheter
c. Aspirate the air from the Y port of the IV tubing.
d. Do nothing since the bubbles could not cause harm to the patient.

11. Nurse Mary is teaching a student nurse in the insertion of a intravenous infusion. She tells the student that:
a. “Insert the catheter at about 30-50 degrees.”
b. “Place a gauze below the IV catheter insertion site before connecting it to the IV fluid tube.”
c. “Instruct the student to tell the patient to hold his breath upon insertion.”
d. Do the taping of the tube before connecting it to the IV tubing.”

12. The following solutions are categorized under hypertonic solution except:
a. D10W b. D5W c. .3NaCl d. D5LR

13. Betty, a newly hired NOD at Davao Medical Hospital was on an AM Shift at the emergency room suddenly. the patient were rushed and
everyone was for IV insertion. Which among her patients should receive priority for an insertion?
a. a 2 year old, asthma patient on nebulization
b. a 35 year old severely dehydrated with sunken eyeballs and poor skin turgor
c. a 14 year old with an order of IV push antibiotics.
d. a newborn on diarrhea with a fever of 39°c

14. one of the most life threatening complication of intravenous insertion is air embolism. Patient maribeth, is on PLR 30 minutes ago, she
complains of chest tightness, air embolism is suspected. Your immediate Nursing action is to:
a. call the physician c. Place the client on a trendelenburg position
b. place the client on a high fowlers position d. give O2 inhalation at a low flow rate
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4th Floor Florentine Bldg. Bonifacio St. Davao City
2865436
15.A patient with 3rd degree burns on his chest and upper extremeties is in need of fluid resuscitation, insertion of intravenous fluids will be
inserted where?
a. Right arm where veins are visible for insertion c. lower extremeties
b.Left metacarpal vein where 2nd degree burns are found d. at the neck veins for poor fluid resuscitation

16. Maria, the staff nurse inserted an IVF to 2year old dengue patient. As a nurse you would now that the intravenous line and catheter will be
replaced when:
a. every after 3 days whether the flow is still patent b. once infiltration sets in
c. when signs of phlebitis appear. d. every 7 days for as long as the catheter is still functional

17. Katrina, the nurse on duty is about to reinsert an intravenous line at KVO rate to a preoperative patient. She then prepares the IV kit
insertion. Ideally, how many tapes should you prepare for the procedure?
a. 5 tapes to secure the IV catheter
b. 4 tapes to secure the IV catheter and 1 tape to anchor the IV tubing
c. 3 tapes to secure the catheter, 2 tapes to anchor the IV tubing and 1 tape to label the IV tubing
d. 1 tapes to secure the catheter, 1 tape to anchor the IV tubing, and 1 tape to label the IV tubing

18. Before insertion of the catheter which of the following assessment should you do first?
a. color and skin integrity b. vein spotting c. LOC d. quality of the vein

19. Assessment of a good vein is very important before IV insertion to prevent complications related to the insertion. As a nurse we may know
this to prevent the following are criteria’s of a good vein for insertion. Except:
a. check if the vein spotted is movable. Find the most immobile c. do vein spotting
b. do vein mapping d. a bigger vein is better than that of a smaller one

Situation: NASOGASTRIC TUBE PLACEMENT

20. A student nurse is doing her return demonstration on nasogastric tube insertion. She explains and tells the skills instructor how to measure
the length of the tube to be inserted. As the student stated “Ma’am I will measure the length of the tube from the earlobe to the tip of the nose to the
xyphoid process.” You will expect the skills instructor to respond and say.
a. “The measurement is correct, go on with the procedure.”
b. “Please repeat the length of measurement, I haven’t heard it well.”
c. “Pardon me ma’am? Please review your procedure.”
d. “Please go on with the next step.”

21. During the insertion of the tube, instruct your patient to position her head in flexion. Which statement will tell you the patient needs further
instruction.
a. the patient bends her head forward and leans towards your direction
b. the patient looks at the ceiling and slowly swallows while inserting
c. the patient bends her head forwa d and drinks milk through a straw
d. all of the above

22. Asepsis is important to prevent complications in all nursing or medical procedures. In an NGT insertion, what do we observe?
a. medical asepsis b. surgical asespsis c. sterile technique d. handwashing before the procedure

23. Madonna, a student nurse asks her clinical instructor on bacteria found on the stomach of our patients. You are overhearing their
conversation and knows that the clinical instructor needs further teaching if she says:
a. “The normal flora found in the stomach strives in an acidic environment.”
b. “We expect to see Helibactor pylori in the stomach.”
c. “E. coli is the normal flora found nad strives in an acidic environment.”
d. “The normal flora also becomes harmful to the body when increased in number.”

24. Before inserting the tube, assessment should be done to prevent complications on insertion. Select all options that apply to the assessment
phase of NGT insertion.
1. Size of Nares 2. LOC 3. Nasal Obstructions 4. Bleeding 5. Nasal Polyps

a. 2,3,5 b. 1,2,3,4,5 c. 1,3,4 d. 3,4,5

Situation: Checking the placement of the nasogastric tube is important to prevent complications.

25. The most crucial part of insertion is checking the placement of the tube. As a nurse you know that there are ways of checking the tube in its
proper place. You know that the best wayt to check for placement is the:
a. radiologic studies c. gastric contents are tested on lithmus paper
b. aspiration of gastric contents d. gurgling sound or whooshing sound upon introduction of 15ml of air/ water

26. A student nruse asks you “How many tests are done to check tube placement? You would say:
a. “there are 4 ways to check tube placement.”
b. “Xray is the most important, it is not required to do the others.”
c. “There are 5 ways to check tube placement and every test is done for verification.”
d. “5 Tests are done by the radiology technician to confirm placement.”

27. In checking the pH of the gastric contents. As a nurse we must know that the normal pH level of our stomach. You are correct when you
explain that:
a. acidic 0-4 b. acidic 0-.04 c. acidic 1-5 d. alkalinic more than 4

28. The purpose why doctors order Nasogastric tube insertion will depend on the client’s need. The following aren’t common reasons for NG
tube insertion. Select All that Applies:
1. compression 2. Decompression 3. Lavage 4. Gavage 5. Feeding 6. Gastric analysis 7. Irrigation
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4th Floor Florentine Bldg. Bonifacio St. Davao City
2865436
a. 1,2,3,4 b. 1,2,3,4,5,6 c. all of the above d. none of the above
Situation: Nurse Jane is in the Am shift at the medical surgical ward. 70% of the patients admitted are diagnosed with Diabetes Mellitus.

29. Nurse Jane is known to the the expert in DM cases. She teaches the newly registered nurse the calibration of the syringes. She asked her to
get the insulin syringe, by her surprise, she was given a tuberculin syringe. You will expect Nurse Jane to say:
a. “Insulin and tuberculin syringes are eh same, its okay to use either of the two.”
b. “Insulin syringes are bigger than the tuberculin syringes.”
c. “TB and Insulin syringes have the same calibration.”
d. “Insulin syringes are expressed in units, while TB syringes are for intradermal use of TB exposures.”

30. Insulin and Tuberculin syringes differ in calibration since that:

a. insulin is expressed in cc c. insulin is expressed in ml
b. insulin is expressed in units d. tuberculin is expressed in units

31. Nurse Jane carries out the doctors order. Patient Mary-ann is for Blood Glucose Testing the following morning. The patient asks you what
this is for, you know that the test is to check the:
a. blood glucose b. blood serum glucagon c. insulin uptake d. blood serum sugar

32. On the night shift before the test. You will instruct your patient to:
a. eat a midnight snack the night of the test c. NPO 6-8 hours before the procedure
b. NPO 12 hours before the procedure d. no preparation is needed

Situation: Hypoglycemia is one of the most life threatening effects during insulin administration.

33. As a nurse you know that before you administer insulin, glucose level is checked to prevent the hypoglycemic effet. Normal range of BGT
is:
a. 50-120mg/dl b.60-110mg/dl c. 80-120mmol d. 70-110mg/dl

34. Theresa is a Type I IDDM patient. She experiences episodes of hypoglycemia hours after intake of insulin. To prevent further complications
of the side effects of the drug. You will instruct Theresa to:
a. eat crackers before you sleep
b. always bring hard candy and eat when signs and symptoms of hypoglycemia is evident
c. drink orange juice at the peak of hypoglycemia
d. always carry an extra dose of insulin injection

35. Signs and symptoms of hypoglycemia include the following except:

a. cold clammy skin b. sweats profusely c. flushed skin d. tremors and nervousness

36. Theresa eats butter and bread in the morning to help fight hypoglycemia. She found out after talking to her endocrinologist that bread creates a
rebound effect. This means to say that the rate at which the blood glucose rise is directly proportional to the rate at which it falls. This is otherwise
known as:
a. glucose tolerance effect b. sondalyn’s effect c. rebound effect d. somogyi’s effect

37. Dolly after a self check on blood glucose test on the glucometer found out that her blood glucose level is only 45mg/ddl. She will:
a. call 911 to bring her toe the nearest hospital c. delay the dose of insulin until she gets told of the order from her physician
b. call the physician and inform her about the result d. eat macaroni and cheese with orange juice then self test again

Situation: Mixing two insulins are nursing functions of the medicating nurse on duty.

38. Nurse Marissa is identifying the difference between NPH and regular insulin. She needs further teaching if she says that:
a. “One classification of insulin is intermediate acting insulin which is the NPH insulin.”
b. “Cloudy Insulin is termed as NPH or Lente for its appearance.”
c. “The peak action of regular insulin is about 1-2 hours while fNPH is about5-6 hours.”
d. “Regular insulin is otherwise classified under short acting which has a duration of 2-4 hours.”

39. Nurse Marissa prepares the equipments, in mixing two insulins and the actual insulin administration. How many needles and syringes will Nurse
Marissa needs for the procedure?
a. 2 syringes, 1 for NPH and 1 for regular
b. 1 syringe, 1 for nph and regular including the injection
c. 3 syringes, 1 for NPH, 1 for regular and 1 for the injection
d. 1 syringe and 1 needle, 1 syringe for aspiration of insulin and the needle to change for injection

40. The first step in mixing insulins is:

a. inject air into the RI b. inject air into the NPH c. aspirate RI first d. aspirate NPH last

41. Nurse Marissa explains the reason why regular insulin should be aspirated first before the NPH. The reason behind this is:
a. NPH acts to breakdown regular insulin absorption c. NPH increases the rate of potency of the regular insulin
b. regular insulin fights the anti insulin properties of the NPH d. regular insulin potency is decreased due to the effect of NPH

42. Which of the following is not included amuont eh following options?

a. intermediate acting insulin b. NPH c. Humalog d. Lente

43. To avoid contact between NPH and regular insulin, the nurse must be aware that:
a. invert NPH while introducing air
b. leave the NPH on the table then gently introduce air ensuring no contact of the needle from the NPH insulin
c. leave the RI in place while introducing air ensuring no contact of the needle
d. aspirate NPH first before RI to avoid contact

44. NPH insulin contains solutes of insulin. Before aspirating the NPH solution the clinical instructor must connect the student if he does:
a. shake the solution vigorously c. rolls the solution between her palms
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4th Floor Florentine Bldg. Bonifacio St. Davao City
2865436
b. ensure that the NPH solution isn’t frothy d. inverts the bottle upon aspiration
45. After mixing two insulins, Nurse Betty is now ready to inject to the patient. Before doing so, what is the most important nursing intervention to
do:
a. verify the informed consent c. mix the solution in the syringe
b. verify calibration and due of insulin d. disinfect the injection site

46. Nurse Dianne was asked by her clinical instructor on the route of insertion of insulin. She knows that she studied correctly when she says that all
of the following are included and related to the question of her CI. Select all that applies
1. subcutaneously 6. 90 degree angle for the obese patient
2. Intradermally 7. 90 degree angele for the IM route
3. Intramuscularly 8. 10-15 degree for emanciated patients
4. 10-15 degree angle for obese
5. 45 degree angle for regular patients

a. 1,2,3 b. 4,5,6,8 c. 1,5,6,7,8 d. 1,5,6,8

47. Rotating injection sites it also one most important responsibility of nurses to:
a. prevent asphyxiation c. prevent dystrophy of insulin muscles
b. prevent lipodystrophy d. promote wound healing from injection

48. As nurses we must know the different types of insulin injections. A student nurse asks you what does NPH insulin stand for. You will tell the
student:
a. “Non-Protamine Humalog or your short acting insulin.” c. “Non-Protamine Hagedorn or your long acting insulin
b. “Non-protamine Hagedorn or your intermediate acting insulin.” d. “Non-Protamine Humalog or your Cloudy insulin.”

49. Nurse Minah injects 20 units of insulin to Mang Rene. After injection, she covers the site with cotton balls and hands over the site with cotton
balls to Mang Rene to hold. Mang Rene then massages the site. She instructs the patient to stop massaging because:
a. it increases the rate of absorption c. its okay to massage
b. it decreases the rate of absorption d. it stabilizes the rate of absorption

50. Nelly, a 24 year old diagnosed with Type 1 DM experiences episodes of hot flushes, and dry skin. She asks you why these symptoms are
occurring. You know that these symptoms are associated with:
a. Diabetes mellitus b. hyperthyroidism c. hyperglycemia d. hypoglycemia