311L module 3 (CP & rationales)

The nurse must obtain a venous blood specimen for culture and sensitivity. The client is very anxious about having the procedure and wants to know each step beforehand. When explaining the procedure, where will the nurse tell the client that the tourniquet will be placed? A. 3 to 4 in (2.5 to 5 com) above the selected site B. 3 to 4 in (7.5 to 10 cm) below the selected site C. 1 to 2 in (2.5 to 5 com) above the selected site D. 1 to 2 in (2.5 to 5 com) below the selected site

A. 3 to 4 in (2.5 to 5 com) above the selected site

The nurse is using a pulse oximeter to monitor a client who is receiving oxygen therapy via a nasal cannula. The nurse explains to the client that which factor might affect the results of pulse oximetry? A. Alterations in circulation. B. Pain medications. C. Thyroid disease. D. Cardiovascular disease.

A. Alterations in circulation. The results of pulse oximetry can be altered by several factors, including alterations in circulation, movement of the client, or various substances depending on the model of the oximeter being used. Cardiovascular disease, thyroid disease, and pain medication do not alter the results of a pulse oximeter.

A nurse is attempting to enlarge the veins of a client before venipuncture. Which techniques are appropriate? Select all that apply. A. Apply a warm compress to the limb before applying the tourniquet. B. Leave the tourniquet in place for up to 5 minutes before attempting venipuncture. C. Lightly tap the skin over the vein. D. Lower the client's arm before applying the tourniquet. E. Ask the client to make a fist.

A. Apply a warm compress to the limb before applying the tourniquet. C. Lightly tap the skin over the vein. D. Lower the client's arm before applying the tourniquet. E. Ask the client to make a fist. To help distend the client's veins, the nurse should have the client make a fist, tap the skin over the vein lightly several times. Lower the client's arm to allow blood to pool in the veins before applying the tourniquet, or apply warm compresses for about 10 minutes before applying the tourniquet. The tourniquet should remain in place no more than 60 seconds to prevent injury, stasis, and hemoconcentration, which may alter results.

When removing the old dressing from the site of a Penrose drain, the nurse notes that some of the dressing material has stuck to the client's skin. What action should the nurse take next? A. Apply sterile saline to loosen the dressing material from the skin. B. Administer an analgesic to the client and warn the client this may be a little painful. C. Gently pull the dressing material off the client's skin and observe for irritation. D. Use an alcohol based adhesive remover to aid in removal of the dressing.

A. Apply sterile saline to loosen the dressing material from the skin. The nurse should apply sterile saline to loosen the dressing material from the skin. If any part of the dressing sticks to the underlying skin, the nurse should use small amounts of sterile saline to help loosen and remove it. Sterile saline moistens the dressing for easier removal and minimizes damage and pain. Gently pulling the dressing off without the saline will likely be painful and may cause irritation to the site. An alcohol based adhesive remover is to remove tape or other adhesive materials.

The nurse notes an unexpected decrease in the amount of drainage in a client's T-tube drain. What action should the nurse take next? A. Assess for any kinks in the tubing. B. Document the decrease in drainage. C. Change the dressing surrounding the drain. D. Increase the suction to the drain.

A. Assess for any kinks in the tubing. The nurse should check the drain tubing for any kinks, because kinked tubing could block any drainage. The nurse should ensure there is not a reason for the decrease in drainage before just documenting it. This type of drain does not have suction. Changing the dressing will not address any kink in the tubing.

The nurse is caring for a client with a Jackson-Pratt drain. Which intervention by the nurse is priority before beginning the dressing change? A. Assessing the need for analgesia B. Checking the client's latest laboratory values C. Gathering the needed supplies D. Assessing the client's need to void

A. Assessing the need for analgesia Although all noted interventions may be indicated, assessing the need for analgesia is priority. The nurse should administer appropriate prescribed analgesic and then allow enough time for the analgesic to achieve its effectiveness before beginning the procedure.

After the venipuncture site has been selected and disinfected, what should the nurse do next? A. Avoid touching the clean site prior to needle puncture. B. Repalpate the venous site before needle puncture. C. Remove the tourniquet and proceed with the needle puncture. D. Quickly proceed with needle puncture before the cleaning solution has dried.

A. Avoid touching the clean site prior to needle puncture. For asepsis, the nurse should avoid touching the clean site prior to needle puncture. The clean site should not be repalpated to avoid contamination. The tourniquet should stay in place during the needle puncture. The cleaning solution should be allowed to dry completely prior to needle puncture.

The nurse is caring for five clients on a busy medical floor. Which tasks can the nurse delegate to unlicensed assistive personnel (UAP)? Select all that apply. A. Bathing and shaving of a client on continuous oxygen at 2 liters per minute via nasal cannula. B. Administering initial oxygenation to a client with a pulse oximeter reading of 88%. C. Applying a face mask to a client with a pulse oximeter reading of 90% on nasal cannula. D. Ambulating in the hall a client who always uses portable oxygen via nasal cannula. E. Reapplying the nasal cannula after the client dislodges it during repositioning.

A. Bathing and shaving of a client on continuous oxygen at 2 liters per minute via nasal cannula. D. Ambulating in the hall a client who always uses portable oxygen via nasal cannula. E. Reapplying the nasal cannula after the client dislodges it during repositioning. If the nasal cannula is removed or dislodged during nursing care activities, such as bathing, shaving, or repositioning, reapplication of the nasal cannula may be performed by UAP. A UAP may ambulate a client that uses portable oxygen, unless the client is unstable. The administration of oxygen by nasal cannula is not delegated to UAP, because assessment by a registered nurse is required.

What assessment would the nurse make prior to using a pulse oximeter to measure oxygen saturation? A. Capillary refill. B. Respiratory rate. C. Blood pressure. D. Pulse farthest away from the monitoring site.

A. Capillary refill. The nurse should assess the pulse nearest to the monitoring site (the wrist) and capillary refill prior to using a pulse oximeter. Brisk capillary refill and a strong pulse indicate that circulation to the site is adequate. Blood pressure and respiratory rate are not monitored at this time.

The nurse is instructing the client about collection of a sputum specimen. Prior to assisting the client, what things should the nurse review with the client? Select all that apply. A. Clear nose and throat before beginning procedure. B. Sit up straight in bed as fully as possible. C. Spit forcefully into the specimen cup. D. Inhale deeply two or three times before trying to obtain specimen. E. Make sure not to rinse mouth with water prior to procedure.

A. Clear nose and throat before beginning procedure. B. Sit up straight in bed as fully as possible. D. Inhale deeply two or three times before trying to obtain specimen. Prior to sputum collection, the client should clear nose and throat to avoid specimen contamination. By inhaling deeply two to three times and sitting up straight in bed as fully as possible, the lungs can more fully expand and that helps to mobilize secretions. The client should not spit forcefully into the specimen cup as this would contaminate the specimen with saliva. The client should also not use water to rinse the oral cavity of excess saliva and any food particles that may contaminate the specimen.

A nurse is collecting a venous blood specimen from an adult for culture and sensitivity. Which actions should the nurse perform? Select all that apply. A. Collect the specimens from two different sites. B. Insert the needle into the vein at a 45-degree angle to the skin. C. Collect two bottles of specimen, totalling 30 mL. D. Clean the client's skin at the puncture site with an antimicrobial swab. E. Collect blood-culture specimens before other specimens. F. Collect the specimens at two different times.

A. Collect the specimens from two different sites. C. Collect two bottles of specimen, totalling 30 mL. D. Clean the client's skin at the puncture site with an antimicrobial swab. E. Collect blood-culture specimens before other specimens. If tests are prescribed in addition to the blood cultures, the nurse should collect the blood-culture specimens before other specimens, to lessen the likelihood that the culture samples will be contaminated due to other tests. In this procedure, a venous blood sample is collected by venipuncture into two bottles (one set), one containing an anaerobic medium and the other an aerobic medium. Currently, best practice is to draw blood one time, obtaining at least 30 mL of blood (for adults) from two different venipuncture sites. Cleaning the client's skin reduces the risk for transmission of microorganisms. With the bevel of the needle up, the nurse should insert the needle into the vein at a 15-degree angle to the skin, not a 45-degree angle.

A nurse is creating a leg exercise regimen for client who is recovering from surgery. Which factors should the nurse consider when recommending leg exercises to this client? Select all that apply. A. Facility protocol B. Client's physical condition C. Cardiovascular intensity of exercise D. Current popularity of the exercise E. Client's individual needs F. Health care provider preference

A. Facility protocol B. Client's physical condition E. Client's individual needs F. Health care provider preference Leg exercises increase venous return through flexion and contraction of the quadriceps and gastrocnemius muscles. It is important to individualize leg exercises to client needs, physical condition, health care provider preference, and facility protocol. Current popularity of the exercise and the cardiovascular intensity of the exercise are not factors to consider.

The nurse is correct when placing the postoperative client in which position for the client to perform incentive spirometry exercises? A. Fowler's B. side-lying C. Trendelenberg D. prone

A. Fowler's The Fowler's (sitting) position allows for adequate chest expansion and mobilization of secretions. Prone would have client facing down and would not allow for adequate chest expansion. Side lying would not allow for adequate chest expansion. Trendelenberg would be used to increase fluid return to the heart and would not allow for adequate chest expansion.

After emptying the drainage from a Jackson-Pratt drain, how will the nurse re-establish suction to the drain? A. Fully compress the bulb and reapply the cap. B. This type of drain does not use suction. C. Reapply the cap and fully compress the bulb. D. Turn the suction back on at the wall unit.

A. Fully compress the bulb and reapply the cap. To re-establish suction after emptying a Jackson-Pratt drain, the nurse should fully compress the bulb and then reapply the cap. Applying the cap before compressing the bulb will not allow the air to escape and, therefore, no suction can be applied. Wall suction is not used with the Jackson-Pratt drain.

The nurse explains to a client with a history of asthma why the health care provider has prescribed an incentive spirometer to be used postoperatively. What is the therapeutic effect of using this device? A. It teaches the client to take deep breaths after surgery. B. It helps the client to relax after surgery. C. It helps the client to cough and remove mucous from the lungs. D. It allows the client to take shallow breaths after surgery.

A. It teaches the client to take deep breaths after surgery. The purpose of the incentive spirometer is to teach the client to take deep breaths after surgery to prevent breathing problems. Coughing is accomplished with performing coughing exercises. It is not used to relax the client.

A nurse must take a client's pulse oximetry reading. The nurse is explaining the technique to the client. Which statements about pulse oximetry are true? Select all that apply. A. Once the oximetry probe is correctly placed, a beam of red and infrared light travels through the tissue and blood vessels. B. Sensors are available for use on the finger, toe, foot, earlobe, forehead, and bridge of the nose. C. Pulse oximetry measurement requires insertion of an arterial line. D. Pulse oximeters display oxygen saturation and respiratory rate. E. A range of 88% to 95% is considered normal oxygen saturation for infants. F. The pulse oximetry sensor can produce accurate results even if circulation to the sensor site is impaired.

A. Once the oximetry probe is correctly placed, a beam of red and infrared light travels through the tissue and blood vessels. B. Sensors are available for use on the finger, toe, foot, earlobe, forehead, and bridge of the nose. The oximetry sensor uses a beam of red and infrared light to calculate the amount of light absorbed by arterial blood. Sensors are available for all of the sites mentioned. Inadequate circulation will result in inaccurate readings. Pulse oximetry measurements are noninvasive. Normal range is 95% to 100%. Pulse oximeters display heart rate, not respiratory rate.

The nurse has attached the probe of a pulse oximeter to the finger of a client to monitor oxygen saturation. The nurse notices that the oximeter reads a low saturation of 88 percent with irregular meter pulsations; however, upon assessment of the client, the nurse finds no symptoms of respiratory distress. What might be causing this failure to obtain an accurate reading? A. Peripheral vascular disease. B. Accumulation of secretion in the lungs. C. Pulmonary embolism. D. An irregular pulse.

A. Peripheral vascular disease. When a client has peripheral vascular disease, the circulation in the hands is compromised. In this situation, the earlobe site should be used for the probe to obtain an accurate reading. An irregular pulse would not affect the oxygen level. With a pulmonary embolism and accumulation of secretion in the lungs, the client would show systems of respiratory distress, which was not the case.

A nurse is performing a nasal swab of a client to aid in the diagnosis of an infectious respiratory tract disease. Which actions should the nurse take? Select all that apply. A. Rotate the swab against the anterior nasal mucosa five times. B. Lightly squeeze the bottom of the collection tube to break the seal on the culture medium. C. Remove the swab immediately after performing the rotations. D. Swab the second naris using a new swab. E. Insert the swab 2 cm into one naris. F. Moisten the swab with sterile water.

A. Rotate the swab against the anterior nasal mucosa five times. B. Lightly squeeze the bottom of the collection tube to break the seal on the culture medium. E. Insert the swab 2 cm into one naris. F. Moisten the swab with sterile water. Moistening the end of the swab minimizes discomfort to the client. Contact with the mucosa is necessary to obtain potential pathogens, so the swab must be inserted 2 cm into the naris. The swab should be rotated against the anterior nasal mucosa for 3 seconds or five rotations, depending on facility policy, and then kept there for 15 seconds (not removed immediately after performing the rotations). Placement of the end of the swab in culture medium and releasing of liquid transport medium is necessary to ensure accurate processing of specimen. The second naris should be swabbed with the same swab used in the first naris, not a new one. Repeating in the second naris ensures an accurate specimen.

The nurse is checking capillary refill to measure circulation in the client's index finger prior to using a pulse oximeter. What would be the next best site to place the probe if circulation is found to be inadequate at this site? A. The bridge of the nose. B. The finger of the other hand. C. The big toe. D. The elbow.

A. The bridge of the nose. If circulation is inadequate at the site, the nurse could use the earlobe or bridge of the nose. These alternate sites are highly vascular alternatives. If these were unavailable, the nurse would use a toe only if lower extremity circulation is not compromised. Peripheral vascular disease is common in lower extremities. The probe is not designed for use on an elbow.

After positioning the client to teach deep-breathing exercises, the nurse asks the client to place the hands on the rib cage. What is the rationale for this action? A. To feel the chest rise. B. To feel the chest lower. C. To feel the lungs collapse. D. To protect the surgical incision.

A. To feel the chest rise. During deep-breathing exercises, the nurse asks the client to put the hands on the rib cage to feel the chest rise and the lungs expand as the diaphragm descends. Splinting, during coughing, protects the surgical incision.

The nurse is caring for a client's wound that has a Jackson-Pratt drain in place. What would be the nurse's next step after emptying the chamber's contents into the graduated collection container? A. Use a gauze pad to clean the outlet. B. Replace the cap on the chamber. C. Put on clean gloves. D. Fully compress the chamber.

A. Use a gauze pad to clean the outlet. The order in which the nurse would perform the steps to care for a Jackson-Pratt drain is (1) empty the chamber's contents completely into the container, (2) use the gauze pad to clean the outlet, (3) fully compress the chamber, and (4) replace the cap. Clean gloves would be put on prior to emptying the chamber.

A nurse is teaching a client how to perform leg exercises. Which postoperative complications may be prevented with leg exercises? A. Venous stasis. B. Hemorrhage. C. Stroke. D. Varicose veins.

A. Venous stasis. Leg exercises assist to prevent muscle weakness, promote venous return, and decrease complications related to venous stasis. Stroke and hemorrhage may be prevented by frequent dressing assessments. Varicose veins are not caused by surgery.

How often will the nurse empty a Jackson-Pratt drain? Select all that apply. A. When the drain is one-half to two-thirds full B. At least every 4 hours C. At least every shift D. Once every 24 hours E. Only when the drain is full

A. When the drain is one-half to two-thirds full B. At least every 4 hours The nurse should empty the Jackson-Pratt drain when the drain is one-half to two-thirds full and at least every 4 hours. The nurse should not wait until the drain is full, because this could interfere with the proper functioning of the drain. Once per shift or once per day is not often enough to catch any early indications of a complication.

The nurse must perform a nasopharyngeal swab for a client. The client asks how he or she should hold the head to make the procedure more comfortable. The nurse instructs the client to place the head in what position? A. tipped backward B. turned toward left C. turned toward right D. tipped forward

A. tipped backward By tipping the head backward, the nasopharynx will be more easily accessible for the swab. By tipping the head forward or turning the head to either side, the nasopharynx may be obscured, making the swab procedure more difficult.

The nurse has presented an educational inservice about collection of sputum specimens and ask participants, "When is the best time to collect a sputum specimen?" Which response by a participant indicates a correct understanding of the material? A. "Immediately after the client consumes a hot beverage" B. "First thing in the morning when the client wakes up" C. "Before the client performs oral care at bedtime" D. "After the client takes a shower"

B. "First thing in the morning when the client wakes up" Secretions accumulate during the night, aiding the collection process. The other times listed are therefore not as effective for sputum collection as is first thing in the morning.

The nurse is educating a client prior to performing a nasal swab for the client to know what to expect. The client asks where the nurse will place the swab. What is the best response by the nurse? A. "Toward the right side of the nasal cavity." B. "Posteriorly along the floor of the nasal cavity." C. "Toward the left side of the nasal cavity." D. "Upward toward the roof of the nasal cavity."

B. "Posteriorly along the floor of the nasal cavity." The swab should be aimed posteriorly along the floor of the nasal cavity. It should never be aimed upward to avoid damage to the nasopharynx. By aiming the swab toward the left or right side, the swab will not pass as easily through the nasopharynx.

Prior to performing a nasopharyngeal swab for a client, the nurse should make the client aware that the swab will be in the nasopharynx for how long before removing? A. 45 to 60 seconds B. 15 to 30 seconds C. 65 to 90 seconds D. 5 to 10 seconds

B. 15 to 30 seconds The nurse should leave the swab in place for 15 to 30 seconds to obtain an adequate specimen. Leaving the swab in place for 5 to 10 seconds would not be enough time to obtain an adequate specimen. The other values are too long and could cause the client unnecessary discomfort.

The nurse is teaching the client about postoperative leg exercises. The nurse would instruct the client to repeat leg exercises how many times? A. 5 times B. 3 times C. 2 times D. 10 times

B. 3 times Clients should perform each leg exercise three times. Leg exercises assist to prevent muscle weakness, promote venous return, and decrease complications related to venous stasis.

What would the nurse use to prepare the site for attachment of a pulse oximeter probe? A. An antimicrobial swab. B. An alcohol wipe. C. Sterile saline solution. D. Warm water.

B. An alcohol wipe. The nurse prepares the site for the probe by cleansing it with an alcohol wipe. This sufficiently cleanses the area since the probe is non-invasive.

What are the expected outcomes when caring for a T-tube drain? Select all that apply. A. The client is able to get out of bed without assistance. B. Care is accomplished without contaminating the wound. C. Care is accomplished without causing trauma to the wound. D. The drain will remain patent. E. The client does not experience pain or discomfort.

B. Care is accomplished without contaminating the wound. C. Care is accomplished without causing trauma to the wound. D. The drain will remain patent. E. The client does not experience pain or discomfort. The expected outcomes when caring for a T-tube drain are that the drain will remain patent, the wound is not contaminated during care, no trauma is caused to the wound and that the client did not experience pain or discomfort. Increasing the ability of the client to get out of bed without assistance is not an expected outcome related to care of a T-tube drain.

The nurse is caring for a client who has a Penrose drain. On assessment, the nurse notes that there is a safety pin on the drain just outside the wound incision area. What action should the nurse take related to this finding? A. Remove the safety pin and clean with an antiseptic preparation. B. Document the presence and location of the safety pin. C. Notify the health care provider of the finding at the incision site. D. Obtain a wound culture to test for possible infection.

B. Document the presence and location of the safety pin. The nurse should document the presence and location of the safety pin, because this is an expected finding. Many times, the surgeon will use a large safety pin inserted into the Penrose drain just outside of the wound to hold the drain in place and prevent it from slipping into the wound. Because this is an expected finding, the other options would not be correct actions to take.

The nurse is performing a nasal swab for a client who has a severe cough. What important step should the nurse take prior to completing the nasal swab procedure? A. Administer PRN dose of cough medication. B. Don gloves and a face shield. C. Have the client blow his or her nose. D. Place a mask over the client's mouth.

B. Don gloves and a face shield. To provide protection from potentially contaminated secretions and air droplets, the nurse should don gloves and a face shield. There is no indication for the client to blow the nose prior to procedure. Placing a mask over the client's mouth during the procedure may hinder his or her breathing during the nasal swab. A PRN dose of cough medication would not be immediately effective and would not protect the nurse from potentially contaminated secretions and air droplets.

When initiating deep-breathing exercises for a postoperative client, what would be the nurse's instructions for the first breath? A. Inhale through the mouth and exhale through the nose. B. Exhale first and breathe in through the nose. C. Exhale first and breathe in through the mouth. D. Inhale deeply and exhale through pursed lips.

B. Exhale first and breathe in through the nose. For the first breath, the nurse would instruct the client to exhale first, breathe in through the nose, and hold the breath for five seconds. The client would then breathe out through the mouth with pursed lips. Deep inhalation promotes lung expansion.

The nurse is caring for a client prior to surgery. The surgeon has prescribed a preoperative nasal swab for the client for Staphylococcus aureus. In addition to the nasal mucosa, Staphylococcus aureus can also be colonized in what other areas of the body? Select all that apply. A. Fingernails B. Hairline C. Eyelids D. Naval E. Perineum

B. Hairline D. Naval E. Perineum Staphylococcus aureus can commonly colonize on the skin in the nose, hairline, perineum, and naval. It is not colonized under the fingernails or eyelids. Nasal swabs are often used as screening tools to identify methicillin-resistant Staphylococcus aureus (MRSA).

The nurse is preparing to teach a client how to perform incentive spirometry. Which concepts should the nurse include? A. Oxygen saturation is expected to decrease during the first few minutes of incentive spirometry. B. Incentive spirometry provides visual reinforcement for deep breathing. C. Proper, frequent use of incentive spirometry can improve pulmonary circulation. D. The client should forcefully exhale into the incentive spirometer and continue to exhale until unable to continue.

B. Incentive spirometry provides visual reinforcement for deep breathing. Incentive spirometry assists the client to perform adequate deep breathing. Incentive spirometry affects ventilation rather than perfusion. Oxygen saturation should increase with the use of incentive spirometry, not decrease. Incentive spirometry is used to enhance inspiratory effort; thus, the client should inhale through the incentive spirometer, not exhale through it.

The nurse is teaching a postoperative client how to use an incentive spirometer. What type of complication may be avoided with the proper use of this device? A. Pressure injuries. B. Pneumonia. C. Pulmonary embolism. D. Skin infection.

B. Pneumonia. An incentive spirometer helps keep the lungs clear from secretions following surgery and helps prevent respiratory complications such as pneumonia. Skin infections can be prevented by using aseptic technique when caring for the wound, pressure ulcers can be prevented by turning the client in bed, and pulmonary embolisms may be prevented by using antiembolism stockings.

The nurse is preparing the site for applying the probe of a pulse oximeter. What would the nurse do to ensure accurate results? A. Wash any deodorant from the client's underarms. B. Remove any nail polish on the client's fingers. C. Apply powder to the site. D. Apply lotion to the site.

B. Remove any nail polish on the client's fingers. When preparing the site for the pulse oximeter probe, the nurse would check if the client has nail polish or fake fingernails applied on the nails. These substances could alter the results of some models of pulse oximeters. The site is prepared by using an alcohol wipe, not lotion or powder. Deodorant does not affect the results of the pulse oximeter.

What is the best way for the nurse to ensure there is not any tension on the tubing when caring for a client with a Jackson-Pratt drain? A. Tape the drain to the dressing material securely below the level of the wound. B. Secure the drain to the client's gown with a safety pin below the level of the wound. C. Apply an abdominal binder over the entire wound and drain to support the site. D. Allowed the Jackson—Pratt drain to hang freely to avoid any kinks in the tubing.

B. Secure the drain to the client's gown with a safety pin below the level of the wound. To ensure there is not any tension on the tubing of a Jackson-Pratt drain, the nurse should secure the drain to the client's gown with a safety pin below the level of the wound. Taping the drain or applying an abdominal binder will keep the bulb compressed and hinder the suction action of the drain. The drain should not be allowed to hang freely because this causes tension on the drain site.

The nurse is assisting a postoperative client to perform leg exercises. Which is the first step in this exercise? A. Extend the legs and make circles with both ankles. B. Straighten the knee, raise the foot, and extend the lower leg for a few seconds. C. Flex or pull the toes toward the chin. D. Point the toes of both legs toward the foot of bed and then relax them.

B. Straighten the knee, raise the foot, and extend the lower leg for a few seconds. The order in which leg exercises are performed is: (1) straighten the knee, raise the foot, and extend the lower leg for a few seconds; (2) point the toes of both legs toward the foot of bed and then relax them; (3) flex or pull the toes toward the chin; and (4) extend the legs and make circles with both ankles.

The nurse observes the client's correct use of the incentive spirometer when what occurs? A. The client does not rest between inhalations into the incentive spirometry tube. B. The client takes slow, deep inhalations into the incentive spirometry tube 5 to 10 times per hour. C. The client takes quick, short breaths in and out of the incentive spirometry tube. D. The client blows forcefully several times into the incentive spirometry tube.

B. The client takes slow, deep inhalations into the incentive spirometry tube 5 to 10 times per hour. The purpose of the incentive spirometer is to aid the client with taking slow, deep inhalations to expand alveoli, mobilize secretions, and decrease risk of pulmonary complications such as pneumonia. The client should not blow into the incentive spirometer. The client should rest in between the slow, deep breaths to prevent dizziness and fatigue.

The nurse is using a pulse oximeter to measure the oxygen saturation for a client with lung cancer. Normally, where would the nurse place the probe of the device? A. The wrist. B. The index finger. C. The big toe. D. The forehead.

B. The index finger. The probe of the oximeter is designed to fit over the client's index finger, which is the most accessible site. If one finger is too large for the probe, another finger can be used.

The nurse is caring for a client who is receiving continuous oxygen at 3 L/minute via nasal cannula. The client's oxygen saturation has consistently been 94% to 96%, but suddenly drops to 86% as the nurse palpates the client's abdomen. The client denies respiratory difficulty or other distress. Which is a likely reason for the client's decreasing oxygen saturation? A. The client is holding his or her breath. B. The nurse has inadvertently stepped on the client's oxygen tubing, occluding the flow of oxygen. C. The client's appendix has ruptured. D. The client has developed a pulmonary embolism and has a ventilation-perfusion mismatch.

B. The nurse has inadvertently stepped on the client's oxygen tubing, occluding the flow of oxygen. A sudden drop in oxygen saturation without clinical signs or symptoms may be caused by disruption of oxygen flow. The information in the question does not support a pulmonary embolism, the client holding his or her breath, or an appendix rupturing.

The preoperative nurse is teaching a client about deep-breathing exercises. The client asks, "Why do I need to learn about this?" Which response by the nurse is correct? A. "These techniques will prevent trapped air from accumulating in your lungs." B. "These types of exercises help distract you from the postoperative pain." C. "After surgery, deep-breathing exercises help to remove anesthetic gasses and mucus and improve oxygen supply to body tissues." D. "If you learn how to perform these exercises correctly, you will not need supplemental oxygen during surgery."

C. "After surgery, deep-breathing exercises help to remove anesthetic gasses and mucus and improve oxygen supply to body tissues." Deep-breathing exercises are intended to help prevent postoperative complications, such as low oxygen levels, accumulation of secretions, and atelectasis.

The nurse is caring for a client who needs venipuncture. The client has IV fluids running in the left forearm. The client asks where the nurse will perform the venipuncture. What is the best response by the nurse? A. "Anywhere above the IV in the left arm." B. "Anywhere below the IV in the left arm." C. "Anywhere in the right arm." D. "Anywhere in the left arm."

C. "Anywhere in the right arm." Performing a venipuncture in the same extremity where IV fluids are running can affect the accuracy of the sample. Therefore, the nurse should attempt venipuncture in the client's right arm, not on the arm with the IV.

The nurse is performing a nasal swab for a client. To ensure client comfort and safety, how far will the nurse insert the swab into the nare? A. 4 cm B. 0.5 cm C. 2 cm D. 5 cm

C. 2 cm The nurse should insert the swab 2 cm into the nare. 0.5 cm may not be far enough to ensure adequate contact with nasal tissue. More than 2 cm may cause pain or damage to nasal mucosa.

A charge nurse is explaining to a new nurse the procedure for obtaining a nasopharyngeal swab. Which statement should the charge nurse make? A. The technique is primarily used for detection of fungal infections. B. Sneezing often occurs when the swab touches the posterior nasopharynx. C. A flexible wire with a cotton tip is used to obtain the sample. D. The swab should be inserted no more than 3 in (7.5 cm) in an adult.

C. A flexible wire with a cotton tip is used to obtain the sample. Use of a flexible wire allows the cotton tip to touch the posterior nasopharynx with as little distress as possible. The technique is primarily used for detection of viral infections. Touching the posterior nasopharynx with the swab causes gagging rather than sneezing. The swab needs to touch the posterior nasopharynx, so it needs to be inserted approximately 6 in (15 cm).

The nurse need to place a dressing under and around a Penrose drain. Which dressing would be best for the nurse to obtain? A. Roll of sterile prewoven gauze B. Nonadherent petrolatum dressing gauze C. A precut 4 × 4 sterile drain sponge D. Sterile 2 × 2 gauze sponge

C. A precut 4 × 4 sterile drain sponge The nurse should obtain the presplit drain sponge to place under and around the drain. The sterile 2 × 2 gauze sponge is too small and does not have a precut split to allow it to go under and around the drain. Nonadherent petrolatum dressing gauze is medicated, which is not indicated. A roll of sterile prewoven gauze is also not precut and would not fit properly around the drain. Gauze should never be cut by the nurse to fit around a drain or stoma site, because this can cause fibers to get into the wound or stoma.

A nurse is caring for a client receiving oxygen at 2 liters per minute via nasal cannula. During the morning assessment, the nurse notes reddened areas at the top of the ears and neck. What actions should the nurse take? Select all that apply. A. Initiate a nonrebreather mask to prevent further skin breakdown. B. Cushion the entire length of the nasal cannula tubing to prevent skin breakdown. C. Apply padding to the tubing that goes over the ears and loosen neck tubing. D. Request a consult by a skin care team to determine further actions. E. Loosen the nasal cannula tubing to ensure the tubing is not too tight.

C. Apply padding to the tubing that goes over the ears and loosen neck tubing. D. Request a consult by a skin care team to determine further actions. E. Loosen the nasal cannula tubing to ensure the tubing is not too tight. The nurse should ensure that reddened areas are adequately padded and that tubing is not pulled too tight, which can cause reddening. If available, a skin care team may be able to suggest methods to prevent further skin breakdown. It is not necessary to cushion the entire length of the cannula tubing, only the areas causing skin breakdown. A nonrebreather mask is not needed for a client who achieves adequate oxygenation receiving 2 liters per minute.

The nurse is teaching a preoperative client how to perform deep-breathing exercises after back surgery. What is the best method to ensure that the client understands the procedure? A. Ask the client's family to describe the procedure. B. Have the client watch a video of the procedure. C. Ask the client for a return demonstration. D. Follow up with printed materials.

C. Ask the client for a return demonstration. The best way to ensure that client teaching has been effective for the psychomotor domain (the integration of mental and muscular activity) is to ask the client for a return demonstration. This ensures that the client is able to perform the exercises properly. Practice promotes effectiveness and compliance. The other methods could also be used, but a return demonstration is the most effective and efficient method.

The nurse is caring for a client who collected a sputum specimen by oneself at the bedside. The client cannot recall when the specimen was collected or how long it has been sitting at the bedside. What is the correct action by the nurse? A. Have client add to current specimen to ensure adequate sample. B. Leave collection time on specimen label blank. C. Discard the specimen and re-collect. D. Send specimen to lab as soon as possible.

C. Discard the specimen and re-collect. The specimen may be old and possibly contaminated and, as such, should be discarded. A new specimen should be collected. The collection time on a specimen label should not be left blank. The client should not add to an old specimen to avoid contamination and inaccurate results.

The nurse has informed a client about the need for a sputum specimen and have provided a specimen container. Later in the day the client states, "I've been collecting spit in the container all day. Is it enough for the test?" Which action is most appropriate? A. Tell the client that the collection technique was improper and will delay diagnosis and treatment. B. Ask the client what time the collection was started and note the start time and approximate volume on the requisition form. C. Discard the specimen container and re-instruct the client about correct collection technique. D. Label the specimen and transport it to the laboratory as soon as possible.

C. Discard the specimen container and re-instruct the client about correct collection technique. The specimen must be sputum rather than saliva and should not be collected over a period of time. Instruct the client that the specimen needs to come from the lungs. Review the procedure for collection. Discard the contaminated container and place a new container at the bedside.

The nurse must obtain a venous blood specimen for culture and sensitivity. Why does the nurse gather two separate collection bottles? A. To ensure the laboratory has an adequate amount of blood for testing. B. A large amount of blood is needed when testing a venous blood specimen for culture and sensitivity. C. Each collection bottle contains a different type of medium allowing for different types of bacteria growth. D. To collect extra blood that can be used for future blood tests as well.

C. Each collection bottle contains a different type of medium allowing for different types of bacteria growth. Each collection bottle for culture and sensitivity contains a different type of medium allowing for different types of bacteria growth. Therefore, blood is not placed in two collection bottles just to ensure there is an adequate amount. Blood is not placed in two collection bottles to be used for future testing.

To ensure the early detection of problems, at a minimum, how often should the nurse check the T-tube drain? A. Every shift B. Every hour C. Every 4 hours D. Every day

C. Every 4 hours The nurse should check the T-tube drain status at least every 4 hours. Check all wound dressings every shift. Checking the drain ensures proper functioning and early detection of problems. Checking every hour is too frequent, unless there is a known problem. The other timeframes would not allow for early detection.

The nurse has emptied the drainage from a Hemovac drain. How will the nurse re-establish the suction? A. Milk and then clamp the drain tubing. B. Recap the drain and keep tubing to gravity. C. Fully compress the drain and reapply the cap. D. Turn the suction back on at the wall outlet.

C. Fully compress the drain and reapply the cap. Once emptied, the Hemovac drain should be fully compressed and the cap reapplied while compressed to re-establish suction. Hemovac drains do not use wall suction. Milking and clamping the drain is not appropriate for a Hemovac drain. Recapping the drain without compressing it first will not re-establish the suction

The nurse is teaching a preoperative client how to perform deep-breathing exercises. What is the next step the client would take after exhaling first and breathing in through the nose? A. Breathe out through the mouth and inhale again through the nose. B. Breathe out through the nose and inhale again through the mouth. C. Hold the breath for five seconds and exhale through pursed lips. D. Hold the breath for ten seconds and exhale through pursed lips.

C. Hold the breath for five seconds and exhale through pursed lips. For the second breath in deep-breathing exercises, the nurse would instruct the client to hold the breath for five seconds and exhale through pursed lips as if whistling.

The nurse is teaching a preoperative client how to cough following a surgical procedure. Which statement accurately describes a step in this procedure? A. Inhale and hold the breath for five seconds; let the breath out in five short coughs. B. Inhale and exhale five times, inhale and hold the breath for three seconds, and lightly cough five times. C. Inhale and exhale three times, inhale and hold the breath for three seconds, and lightly cough three times. D. Inhale and hold the breath for five seconds; let the breath out in five deep hacking coughs.

C. Inhale and exhale three times, inhale and hold the breath for three seconds, and lightly cough three times. The correct procedure for coughing after surgery is to inhale and exhale three times, inhale and hold the breath for three seconds, lightly cough three times, take another deep breath, and strongly cough again two times. Coughing helps to remove retained mucous from the respiratory tract.

A nurse is caring for a client who has spontaneous respirations and needs to have oxygen administered at a FiO2 of 100%. Which oxygen delivery system should the nurse use? A. Venturi mask B. Simple mask C. Nonrebreather mask D. Nasal cannula

C. Nonrebreather mask A nonrebreather mask is the only device that can deliver an FiO2 of 100% to a client without a controlled airway. A Venturi mask delivers a maximum FiO2 of 55%. A nasal cannula delivers a maximum FiO2 of 44%. A simple mask delivers a maximum FiO2 of 60%.

A nurse is assisting a surgeon who will be placing a hollow, open-ended rubber tube in a client with an abscess to drain the wound. This drain will be placed such that one end will be in the abscess and the other will pass through an opening in the skin known as a stab wound. The nurse recognizes that which type of drain is needed? A. Hemovac drain B. T-tube drain C. Penrose drain D. Jackson—Pratt drain

C. Penrose drain A Penrose drain is a hollow, open-ended rubber tube. It allows fluid to drain via capillary action into absorbent dressings. Penrose drains are commonly used after a surgical procedure or for drainage of an abscess. After a surgical procedure, the surgeon places one end of the drain in or near the area to be drained. The other end passes through the skin, directly through the incision or through a separate opening referred to as a stab wound. A biliary drain, or T-tube, is sometimes placed in the common bile duct after removal of the gallbladder (cholecystectomy) or a portion of the bile duct (choledochostomy). The tube drains bile while the surgical site is healing. A Jackson-Pratt (J-P) or grenade drain collects wound drainage in a bulblike device that is compressed to create gentle suction. It consists of perforated tubing connected to a portable vacuum unit. A Hemovac drain is placed into a vascular cavity where blood drainage is expected after surgery, such as with abdominal and orthopedic surgery. The drain consists of perforated tubing connected to a portable vacuum unit.

A nurse is preparing to collect a venous blood specimen for culture and sensitivity from a client. The client has large, distended, highly visible veins in both arms. Which action should the nurse take when collecting blood from this client? A. Apply warm compresses to the selected site on the arm 15 to 20 minutes before venipuncture. B. Stop the procedure and notify the client's health care provider. C. Perform venipuncture on an arm without a tourniquet. D. Perform venipuncture using veins in the lower extremities.

C. Perform venipuncture on an arm without a tourniquet. When performing venipuncture on a client who has large, distended, highly visible veins, the nurse should simply proceed without using a tourniquet to minimize the risk for hematoma. The nurse should not use veins in the lower extremities for venipuncture, because of an increased risk of thrombophlebitis. Applying warm compresses to the selected site 15 to 20 minutes before venipuncture is done to aid in distending veins that are difficult to locate; thus, this action is not necessary in this case, as the veins are already distended. There is no need to stop the procedure or notify the client's health care provider.

Which postoperative complications can be reduced by appropriate client teaching about deep-breathing exercises? Select all that apply. A. Wound infection B. Deep vein thrombophlebitis C. Pneumonia D. Atelectasis E. Bronchitis F. Severe hypoxemia

C. Pneumonia D. Atelectasis E. Bronchitis F. Severe hypoxemia Deep-breathing exercises can decrease respiratory complications. Deep vein thrombophlebitis and wound infection are unrelated to deep-breathing exercises.

A nurse is caring for a client who will be undergoing removal of the gall bladder. Which type of drain should the nurse expect the surgeon to place in the client's common bile duct to drain bile while the surgical site is healing? A. Penrose drain B. Jackson—Pratt drain C. T-tube drain D. Hemovac drain

C. T-tube drain A biliary drain, or T-tube, is sometimes placed in the common bile duct after removal of the gallbladder (cholecystectomy) or a portion of the bile duct (choledochostomy). The tube drains bile while the surgical site is healing. A Penrose drain is a hollow, open-ended rubber tube. It allows fluid to drain via capillary action into absorbent dressings. Penrose drains are commonly used after a surgical procedure or for drainage of an abscess. After a surgical procedure, the surgeon places one end of the drain in or near the area to be drained. The other end passes through the skin, directly through the incision or through a separate opening referred to as a stab wound. A Jackson-Pratt (J-P) or grenade drain collects wound drainage in a bulblike device that is compressed to create gentle suction. It consists of perforated tubing connected to a portable vacuum unit. A Hemovac drain is placed into a vascular cavity where blood drainage is expected after surgery, such as with abdominal and orthopedic surgery. The drain consists of perforated tubing connected to a portable vacuum unit.

The nurse is caring for a client who had abdominal surgery yesterday and is reluctant to cough and perform deep breathing. Which strategy will most likely increase the client's willingness to cough and perform deep breathing? A. Administer respiratory treatments to encourage coughing. B. Remind the client of the serious complications that can result from ineffective coughing and deep breathing. C. Teach the client how to splint the abdomen while coughing. D. Assist the client to a side-lying position to cough.

C. Teach the client how to splint the abdomen while coughing. Splinting the abdomen decreases discomfort while coughing. Telling the client about complications will be less effective that teaching splinting techniques. Respiratory treatments are not indicated for cough production. Side-lying position is less effective than upright positioning to clear secretions and expand the lungs.

A nurse takes a client's pulse oximetry reading and finds that it is normal. What does this finding indicate? A. The client's red blood cell (RBC) count is in the normal range. B. The client's oxygen demands are being met. C. The client's available hemoglobin is adequately saturated with oxygen. D. The client's respiratory rate is in the normal range.

C. The client's available hemoglobin is adequately saturated with oxygen. Pulse oximetry is a noninvasive technique that measures the arterial oxyhemoglobin saturation (SaO2 or SpO2) of arterial blood. This test measures only the percentage of oxygen carried by the available hemoglobin. Thus, even a client with a low hemoglobin level could appear to have a normal SpO2 because most of that hemoglobin is saturated. However, the client may not have enough oxygen to meet body needs. A normal pulse oximetry reading does not necessarily indicate a normal RBC count or heart rate.

The nurse is teaching a preoperative client how to perform deep-breathing exercises. How many times and how often would the client be instructed to perform these exercises following surgery? A. Three times every three to four hours. B. Two times every three to four hours. C. Three times every one to two hours. D. Two times, every one to two hours.

C. Three times every one to two hours. The client would perform deep-breathing exercises three times every one to two hours for the first 24 hours after surgery to promote lung expansion and volume.

A nurse is instructing a client in how to perform leg exercises following surgery. The client asks the nurse, "Why do I have to do these exercises?" Which is the health reason the nurse should mention? A. To improve the efficiency of the heart B. To increase flexibility in the joints C. To increase venous return of blood to the heart D. To strengthen the leg muscles

C. To increase venous return of blood to the heart During surgery, venous blood return from the legs slows. In addition, some client positions used during surgery decrease venous return. Thrombophlebitis, deep vein thrombosis, and the risk for emboli are potential complications from circulatory stasis in the legs. Leg exercises increase venous return through flexion and contraction of the quadriceps and gastrocnemius muscles. Although leg exercises may also strengthen the leg muscles, improve the efficiency of the heart, and increase flexibility, the health reason to perform them following surgery is to increase venous return of blood to the heart.

The nurse on a telemetry unit is assessing oxygen saturation of a client admitted with severe peripheral edema using a pulse oximeter. The nurse obtains a weak and inaccurate pulse oximeter reading. What actions constitute the correct response by the nurse? Select all that apply. A. Recheck the pulse oximeter reading peripherally in 2 hours. B. Transfer the pulse oximeter probe to one of the great toes. C. Use an ear pulse oximeter probe on one of the client's ears. D. Request a prescription for an arterial blood gas level by the lab. E. Move the pulse oximeter probe to a finger on the opposite hand.

C. Use an ear pulse oximeter probe on one of the client's ears. D. Request a prescription for an arterial blood gas level by the lab. The nurse should first use an ear pulse oximeter to try to get a more accurate reading. If that is not effective and an accurate oxygen blood saturation is required, the nurse could request an arterial blood gas test. Decreased arterial blood flow to the extremities from edema could influence the accuracy of the reading if it is performed peripherally on the fingers or toes.

How would the nurse secure a Jackson-Pratt drain after emptying it? A. With a safety pin, secure the drain to the side of the bedding. B. With tape, secure the drain to the client's gown above the wound. C. With a safety pin, secure the drain to the client's gown below the wound. D. With a safety pin, secure the drain to the client's gown above the wound.

C. With a safety pin, secure the drain to the client's gown below the wound. After performing drain care, the nurse would secure the Jackson-Pratt drain to the client's gown below the wound with a safety pin, making sure there is no tension on the tubing.

What is the best way for the nurse to clean the wound site in a client with a Penrose drain? A. in a wedge pattern from pin site to outer edge of wound and repeat B. in a circular motion beginning at the outer edge of the wound and moving in toward the pin site C. in a circular motion beginning at the pin site and moving outward toward the edge of the wound D. in an up-and-down pattern beginning on left side of pin and then to right side

C. in a circular motion beginning at the pin site and moving outward toward the edge of the wound The best way is to clean the site using a circular motion beginning at the pin site and moving outwards. The nurse should begin at the drain insertion site and slowly move in a circular motion toward the outside or periphery of the drain site. This helps to ensure that cleaning is done from the cleanest area of the wound site or drain site to least clean areas and does not contaminate the wound. Using a wedge pattern or an up-and-down pattern is more likely to cause contamination of the wound as the nurse cleans from the cleanest area, out to the least clean and then returns to most clean areas to repeat the procedure possibly bringing bacteria or other contaminants to the wound area. Using a circular motion beginning at the outer edge of the wound would be cleaning from the most contaminated area into the least contaminated area putting the client at increased risk of infection.

A health care provider prescribes oxygen for a client at 4 liters per minute via a nasal cannula after an initial pulse oximeter reading of 88% on room air. Which is the priority client assessment that the nurse should make prior to administering the oxygen? A. apical heart rate and rhythm B. blood pressure and pulse C. respiratory rate and effort D. skin alterations and edema

C. respiratory rate and effort Prior to administering oxygen to a client, the nurse should make an assessment of the client's respiratory status, including respiratory rate, effort, and lung sounds. The nurse would note any signs of respiratory distress, such as tachypnea, nasal flaring, use of accessory muscles, or dyspnea. The nurse should also assess the client's oxygen saturation to provide a baseline for evaluating the effectiveness of oxygen therapy. It is not necessary to assess blood pressure or pulse, apical heart rate or rhythm, or skin alterations and edema prior to administering oxygen via a nasal cannula, although these may need assessment after the nasal cannula is applied.

The nurse is preparing to perform venipuncture to obtain a venous blood sample. Place the following steps in the correct order. Insert the needle, bevel up, at a 15-degree angle. Clean client's skin with antimicrobial swab. Apply gentle pressure to the puncture site. Hold the client's arm in a downward position. Reapply a tourniquet 3 to 4 in (3.75 to 10 cm) above the puncture site. Release tourniquet when blood flows into collection tube.

Clean client's skin with antimicrobial swab. Reapply a tourniquet 3 to 4 in (3.75 to 10 cm) above the puncture site. Hold the client's arm in a downward position. Insert the needle, bevel up, at a 15-degree angle. Release tourniquet when blood flows into collection tube. Apply gentle pressure to the puncture site. Cleaning the client's skin reduces the risk for transmission of microorganisms. Use of a tourniquet increases venous pressure to aid in vein identification. Holding the client's arm down facilitates inserting the needle. Positioning the needle at the proper angle reduces the risk of puncturing through the vein. Tourniquet removal reduces venous pressure and restores venous return to help prevent bleeding and bruising. Applying pressure to site after needle removal prevents injury, bleeding, and extravasation into the surrounding tissue, which can cause a hematoma.

The nurse is preparing to perform a nasopharyngeal swab for a client. The client asks approximately how far the nurse will insert the swab. What will the nurse tell the client? A. "8 inches (20 centimeters)." B. "2 inches (5 centimeters)." C. "4 inches (10 centimeters)." D. "6 inches (15 centimeters)."

D. "6 inches (15 centimeters)." The nurse should insert the swab 6 inches (15 centimeters), which is the approximate distance from the nose to the ear. If the swab is only inserted 2 inches (5 centimeters) or 4 inches (10 centimeters), an adequate specimen may not be obtained. Inserting the swab more than 6 inches (greater than 15 centimeters) could damage the nasopharynx.

The nurse is caring for a female client who needs venipuncture. The client has a history of breast cancer. What is an important assessment question for the nurse? A. "Have you had a recent fever?" B. "Have you had chemotherapy?" C. "Have you been diagnosed with anemia?" D. "Have you had a mastectomy?"

D. "Have you had a mastectomy?" Venipuncture is not recommended in the extremity located on the same side as the previous mastectomy, due to the increased risk of lymphedema. The opposite extremity should be used if possible. Previous chemotherapy should not have a bearing on current venipuncture. Anemia should not affect venipuncture. Recent fever would not preclude regular venipuncture procedure.

The nurse is assisting the client with collection of a sputum specimen. The client asks the nurse why it is necessary to rinse the mouth with water before beginning the procedure. How should the nurse respond? A. "Water will help to ensure an adequate sample is obtained." B. "Water will help to moisten the oral cavity to aid with expectoration." C. "Water will help to sterilize the oral cavity to avoid specimen contamination." D. "Water will help to rinse the oral cavity of excess saliva and any food particles."

D. "Water will help to rinse the oral cavity of excess saliva and any food particles." Water will help to rinse the oral cavity of excess saliva and any food particles that may contaminate the specimen. A moistened oral cavity will not necessarily aid with sputum expectoration or adequate sample. Water does not sterilize the oral cavity.

A nurse is explaining to a client about coughing following surgery. Which teaching statements follows the recommended guidelines? A. "If you need to cough, try to cough as lightly as possible so your incision will not be disturbed." B. "If you cough, turn your head away from the incision to protect it from microorganisms." C. "Try not to cough following surgery as it might disrupt your stitches." D. "When coughing, apply firm pressure on the incision with a bath blanket to minimize discomfort."

D. "When coughing, apply firm pressure on the incision with a bath blanket to minimize discomfort." The client is encouraged to cough after surgery to remove secretions from the lungs. Placing a bath blanket or pillow over the incision when coughing decreases client discomfort.

The nurse is educating a client prior to performing a nasal swab for the client to know what to expect. The nurse tells the client that after inserting the swab into the nare, the nurse will rotate the swab how many times? A. 10 rotations B. 1 rotation C. 2 rotations D. 5 rotations

D. 5 rotations To ensure adequate contact with nasal tissue, the nurse should rotate the swab for five rotations. Rotating 1 or 2 times will not adequately capture the nasal cells and rotating 10 times is not indicated for a routine nasal swab.

The nurse is setting up the equipment needed to deliver oxygen to a postsurgical client via a nasal cannula. After connecting the nasal cannula to the oxygen source and flow meter, what is the next action the nurse should perform? A. Insert the nasal cannula into the client's nostrils. B. Assess the client's respiratory rate and effort. C. Instruct client to breathe through the nose with the mouth closed. D. Adjust the flow rate to the prescribed amount.

D. Adjust the flow rate to the prescribed amount. After connecting the nasal cannula to the oxygen source and flow meter, the nurse would adjust the flow rate to the prescribed amount. The nurse would then check the flow, insert the nasal cannula into the client's nostrils, and instruct the client to breathe through the nose with the mouth closed to achieve optimal oxygen delivery. The respiratory rate and effort would be assessed prior to setting up the nasal cannula equipment and flow meter.

The nurse is using a pulse oximeter to monitor a client's oxygen saturation following abdominal surgery to ensure adequate oxygenation. The health care provider has set a parameter of 92%. How would the nurse maintain this parameter? A. Administering oxygen to the client when the oxygen saturation level has reached 92%. B. Removing the flow of oxygen to the client when 92% oxygen saturation has been reached. C. Adjusting the flow of oxygen to maintain an oxygen saturation level at or below 92%. D. Adjusting the flow of oxygen to maintain an oxygen saturation level at or above 92%.

D. Adjusting the flow of oxygen to maintain an oxygen saturation level at or above 92%. The health care provider sets the parameter to ensure that the client maintains the desired level of saturation, in this case 92% or higher. To ensure adequate oxygenation for the client, the nurse titrates the flow of oxygen based on the pulse oximeter measurement to maintain 92% saturation or above. A constant flow of oxygen is desired to maintain the saturation level, not applying and removing the oxygen as needed.

Where should the nurse position the drain collection bag for the T-tube drain to facilitate proper drainage? A. Below the client's heart level. B. Anywhere on the bedside rails. C. Above the client's waist. D. Below the level of the wound.

D. Below the level of the wound. To best ensure proper drainage, the nurse should position the drain collection bag below the level of the wound, because drainage in the tubing drains via gravity. Placing the drain level with or higher than the wound prevents proper drainage. Using the guideline of placing the T-tube drain below the client's heart level or above the client's waist does not ensure it is below the level of the wound and can drain via gravity. For example, if a client had a drain from a hip surgery, the drain collection bag would need to be below the client's hip area. The nurse should never hang anything on the bedside rails as these are meant to be raised and lowered and do not ensure proper placement.

A nurse is gathering the necessary equipment to empty a client's Hemovac drain. Which personal protective equipment (PPE) would be most essential for the nurse to use at a minimum? A. Mask B. Face shield C. Gown D. Clean gloves

D. Clean gloves

A client has undergone surgery and has a Hemovac drain in place. When providing care to this client, the nurse would monitor the drain status at which frequency? A. Every 2 hours B. Every hour C. Every 8 hours D. Every 4 hours

D. Every 4 hours The nurse should check the drain status every 4 hours. Checking the drain ensures proper functioning and early detection of problems. The nurse should empty and reengage suction (compress device) when device is half to two-thirds full. The nurse should check all wound dressings at least every shift.

The nurse is inserting a nasal cannula into the client's nostrils to improve oxygenation. To correctly insert the curved prongs of the cannula, what would the nurse do? A. Follow the angle of the nose with the prongs pointed upward. B. Follow the angle of the nose with the prongs outside the nostrils. C. Insert only one prong and adjust airflow into one nostril at a time. D. Follow the angle of the nose with the prongs pointed downward.

D. Follow the angle of the nose with the prongs pointed downward. When inserting the prongs of the cannula, the nurse would follow the natural angle of the nose and point the prongs downward. Correct placement of the prongs and fastener facilitates oxygen administration and client comfort; pointing the prongs upward or placing them outside of the nostrils would hinder optimal oxygenation for the client. It is not necessary to adjust airflow for one nostril at a time.

The nurse is teaching deep-breathing exercises to a client who is undergoing thoracic surgery. In what position would the nurse place the client for these exercises? A. Prone B. Trendelenberg C. Side-lying D. Fowler's

D. Fowler's The nurse would put the client in the Fowler's (sitting) position to promote chest expansion and lessen exercise of the abdominal muscles.

The nurse is caring for a postoperative client after abdominal surgery. Why is it important to splint the client's incision during coughing exercises? A. It will decrease risk of incisional infection. B. It will ensure that no incisional bleeding will occur. C. It will decrease risk of postoperative pneumonia. D. It will support the incision and decrease pain.

D. It will support the incision and decrease pain. Bleeding can occur even with incisional splinting, and incisional assessment should be made before and after the exercises. Splinting does support the incision and decrease pain. While the coughing exercises will help decrease risk of postoperative pneumonia, the splinting of the incision is not a factor in that risk. Splinting of the incision should not change the client's risk of incisional infection.

After emptying a client's Hemovac drain, the nurse re-establishes suction and closes the cap. Which action would the nurse do next? A. Change the dressing at the drain site. B. Measure the amount of drainage in the graduated container. C. Perform hand hygiene. D. Secure the drain to the client's gown below the level of the wound.

D. Secure the drain to the client's gown below the level of the wound. After re-establishing suction and closing the cap, the nurse would then secure the drain to the client's gown below the level of the wound. Then the nurse would measure and record the character, color, and amount of the drainage, discard the drainage according to facility policy, remove gloves and perform hand hygiene. Next, the nurse would put on clean gloves and perform drain site care.

The nurse is turning on the pulse oximeter and notices a bar form on the machine. What does this bar represent? A. Hemoglobin level. B. Pulse rate. C. Oxygen levels. D. Signal strength.

D. Signal strength. The pulse oximeter machine has a bar or wave form on the front of the machine that indicates the signal strength. The hemoglobin level is not tested by the pulse oximeter. The oxygen level and pulse rate are shown as numbers on the machine.

The nurse is teaching a client about splinting and coughing postoperatively. What position would the nurse teach the client to assume for coughing? A. Lying flat on the back. B. Sitting up partially reclined. C. Lying flat on the side. D. Sitting up and leaning forward.

D. Sitting up and leaning forward. The nurse would teach the client to sit up and lean forward for coughing exercises. This position facilitates removal of retained mucus from the respiratory tract when coughing.

A nurse needs to obtain a venous blood sample from a term neonate. On the basis of recent research, which is the method of choice for collecting this client's sample? A. Venipuncture with standard needle B. Heel lance C. Finger lancet D. Venipuncture with butterfly needle

D. Venipuncture with butterfly needle Recent research indicates that venipuncture, when performed by a skilled phlebotomist, appears to be the method of choice rather than a heel lance, which is more painful. The nurse should use butterfly needles, as appropriate, for obtaining blood from infants and small children. A finger lancet is used to obtain a capillary blood sample for glucose testing in adults.

The nurse is checking a client's oxygen saturation level using a pulse oximeter. How should the probe be placed on the finger? A. The sensors are automatically aligned when placed on the finger. B. With the light-emitting sensor turned on and the light-receiving sensor turned off. C. With the light-emitting sensor and light-receiving sensor adjacent to each other. D. With the light-emitting sensor and light-receiving sensor opposite each other.

D. With the light-emitting sensor and light-receiving sensor opposite each other. When placing the probe of a pulse oximeter on the client's finger, the nurse must ensure that the light-emitting sensor and light-receiving sensor are aligned opposite each other. Secure attachment and proper alignment promote satisfactory operation of the equipment and an accurate reading of the oxygen saturation level. It is not necessary to check this alignment if the probe is placed on the forehead or bridge of the nose.

The nurse is caring for a Jackson-Pratt drain. Place in order, from first to last, the actions the nurse will perform. Use all options. Place the graduated collection container under the drain outlet. Empty the bulb's contents into the collection chamber. Replace the cap on the bulb. Fully compress the bulb. Remove the cap from the bulb. Wipe the outlet of the bulb with a sterile gauze pad.

Place the graduated collection container under the drain outlet. Remove the cap from the bulb. Empty the bulb's contents into the collection chamber. Wipe the outlet of the bulb with a sterile gauze pad. Fully compress the bulb. Replace the cap on the bulb. When caring for a Jackson—Pratt drain, the nurse should first place the graduated collection container under the drain outlet, then remove the cap from the bulb, and then empty the bulb's contents into the collection chamber, being careful not to contaminate the outlet. Once empty, the nurse should wipe the outlet of the bulb with a sterile gauze pad, fully compress the bulb, and finally, replace the cap on the bulb.

After assessing a client's Hemovac drain, the nurse prepares to empty it. After emptying the contents into a graduated container, the nurse completes the next steps. Place the steps below in the order in which the nurse would perform them. Use all options. Secure the device to the client's gown. Check the patency of the equipment. Compress the chamber. Wipe the outlet with a gauze pad. Apply the cap.

Wipe the outlet with a gauze pad. Compress the chamber. Apply the cap. Check the patency of the equipment. Secure the device to the client's gown. Once the nurse empties the chamber's contents completely into the container, the nurse would use the gauze pad to wipe the outlet. Then the nurse would fully compress the chamber by pushing the top and bottom together with the hands, keeping the device tightly compressed while applying the cap. Next, the nurse would check the patency of the equipment and make sure the tubing is free from twists and kinks. Finally, the nurse would secure the Hemovac drain to the client's gown below the wound with a safety pin, making sure that there is no tension on the tubing.