CRE Review.... Fundamentals
D- For fecal occult blood testing at home, the stool specimens cannot be contaminated with water or urine; three specimens from three different bowel movements are required; some proteins such as red meat, fish, and poultry can alter the test results; and a blue color indicates blood in the stool.
A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following should the nurse include when explaining the procedure to the client? A. Eating more protein is recommended prior to testing. B. One stool specimen is sufficient for testing. C. A red color change indicates a positive test. D. The specimen cannot be contaminated with urine.
B,C,D,F- Prolonged diarrhea leads to dehydration, which is characterized by tachycardia, hypotension, fever, lethargy, poor skin turgor, and abdominal cramping. Peripheral edema is more likely to be caused by a fluid overload rather than a fluid deficit.
4. A nurse is caring for a client who has had diarrhea for the past 4 days. When assessing the client, the nurse should expect which of the following findings? (Select all that apply.) A Bradycardia B Hypotension C Fever D Poor skin turgor E Peripheral edema F Abdominal cramping
A- Planning for several rest periods during morning care will help prevent fatigue and continue to foster independence. Fatigue and dyspnea are not reasons to eliminate morning care. Performing all of the client's care or having a family member do it will reduce the client's independence.
A client experiences dyspnea and reports feeling tired after completing her morning care. Which of the following should the nurse include in the client's plan of care for the next day? A. Plan for several rest periods during morning care. B. Do not offer any morning care. C. Perform all of the client's care as quickly as possible. D. Ask a family member to come in to give the client a bath.
C- Rationale: The symptoms provided describe tachypnea or quick shallow breaths; intercostal retractions, or indrawing between the ribs; hemoptysis, or the presence of blood in the sputum; and stridor, or a shrill, harsh sound heard during inspiration with laryngeal obstruction. Bradypnea is abnormally slow respirations (options 1 and 2). Substernal retractions are indrawing below the xiphoid process (options 2 and 4), and wheezing is a high-pitched whistling sound (option 4).
A client presents with quick shallow breaths indrawing between the ribs, and bloody sputum. Upon auscultation, the client is found to have a shrill harsh sound heard during inspiration. Which assessments most accurately describe this client? A. Bradypnea, intercostal retractions, productive cough, and wheezing B. Bradypnea, substernal retractions, hemoptysis, and stridor C. Tachypnea, intercostal retractions, hemoptysis, and stridor D. Tachypnea, substernal retractions, productive cough, and wheezing
D- This radial pulse does not require immediate medical treatment; therefore, the nurse should next measure the client's apical pulse to assess the client's status further. The nurse should then report the findings to the provider, who will then decide if the client requires telemetry and an electrocardiogram.
A nurse is checking the vital signs of a 92-year-old client. The client's radial pulse has an irregular beat about every fifth or sixth beat. The rate is 92/min. The client is asymptomatic. The nurse should do which of the following? A. Report the findings to the provider immediately. B. Place the client on telemetry. C. Obtain an electrocardiogram. D. Check an apical pulse for 60 seconds and note any pulse deficits.
A- A clogged catheter causes the bladder to fill and stimulates the need to urinate. Reassuring the client that it is not possible to urinate is a nontherapeutic response. The patency of the tube must be checked before replacing the client's catheter. It is not necessary to contact the provider. The nurse can determine whether or not the tube is patent and replace the tube if necessary without a new order.
A client with an indwelling catheter reports a need to urinate. Which of the following interventions should the nurse perform? A. Check to see if the catheter is patent. B. Reassure the client that it is not possible for her to urinate. C. Recatheterize the client with a larger-gauge catheter. D. Notify the provider.
C- Rationale: In hypertension stage 1, the systolic reading falls between 140 and 159 mmHg or the diastolic reading falls between 90 and 99. A normal blood pressure reading (option 1) is a systolic reading of less than 120 mmHg, and a diastolic reading of less than 80 mmHg. In prehypertension (option 2), the systolic is between 120 and 139 mmHg or the diastolic is between 80 and 89 mmHg. In hypertension stage 2 (option 4), the systolic reading is greater than 160 mmHg or the diastolic is greater than 100 mmHg.
A client's blood pressure reading is 144/96. In which classification does this blood pressure reading qualify? A. Normal B. Prehypertension C. Hypertension, stage 1 D. Hypertension, stage 2
A-Tap water is a hypotonic solution that can cause water toxicity. It should not be repeated. The nurse should clarify the order with the provider. Explaining the procedure to the client, ensuring that the tap water is not too hot, and keeping the amount to less than 1,000 mL are not pertinent if the enema should not be repeated. NCLEX®
A nurse is caring for a client for whom a tap water enema is prescribed, to be repeated until the return is clear. Which of the following actions should the nurse take? A. Clarify the order with the provider. B. Explain the procedure to the client. C. Ensure that the tap water is not too hot. D. Keep the amount per enema to less than 1,000 mL.
B-The greatest risk to the client is aspiration pneumonia. Therefore, the first action the nurse should take is to stop the feeding so that no more formula can travel to the lungs. Auscultating for breath sounds, obtaining a chest x-ray, and providing oxygen are all important actions, but none of them is the highest priority.
A nurse is caring for a client receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority if aspiration of tube feeding is suspected? A. Auscultate breath sounds. B. Stop the feeding. C. Obtain a chest x-ray. D. Provide oxygen.
C-Most nosocomial infections develop in the urinary tract, and regular cleaning of the perineal area along with catheter care reduces the number of micro-organisms. Assessing the client's ability to void independently, placing an absorbent pad under the client, and giving the client a diet high in fiber will not prevent a nosocomial infection. NCLEX®
A nurse is caring for a client who has been transferred from a long-term care facility to an acute care setting. An indwelling urinary catheter was inserted just prior to her transfer. Which of the following tasks will help prevent the development of a nosocomial infection? A. Assessing the client's ability to void independently B. Placing an absorbent pad under the client to protect the bed in case of incontinence C. Frequently cleaning the client's perineal area and properly caring for her catheter D. Giving the client a diet high in fiber to prevent constipation
C- Fowler's position facilitates maximal lung expansion and thus optimizes breathing. Supine, dorsal recumbent, and lateral positions will not facilitate breathing. NCLEX®
A nurse is caring for a client who is having difficulty breathing. The nurse should place the client in which of the following positions? A. Supine B. Dorsal recumbent C. Fowler's D. Lateral Fowler's position facilitates maximal lung expansion and thus optimizes breathing. Supine, dorsal recumbent, and lateral positions will not facilitate breathing. NCLEX®
A- This client has a broken femur, and her BP may be elevated due to pain. The nurse should ask if she is having pain and continue a full pain assessment. If the client's BP is still elevated after pain interventions, the nurse should report this finding to the provider. This client needs further assessment at this time, so returning in 30 min is not appropriate. There is no indication for orthostatic pressures, and it might be difficult to have the client sit or stand with a fractured femur.
A nurse is checking the vital signs of a newly admitted client who has a fractured femur. The client's BP is 140/94 mm Hg. The client denies any history of hypertension. The nurse should do which of the following? A. Ask the client if she is having pain. B. Report the elevated BP to the provider. C. Return in 30 min to recheck the BP. D. Check orthostatic BP.
B- Rationale: Rectal thermometers provide a reliable measurement, but the presence of stool may interfere with thermometer placement. Oral temperature readings are accessible and convenient, but can be inaccurate if the client has just ingested hot or cold food or fluid or been smoking (option 1). A temporal artery measurement is safe, noninvasive, and very fast (option 3). A tympanic membrane measurement is readily accessible, reflects the core temperature, and is very fast as well (option 4).
A nurse is considering the different sites for body temperature measurement. Which statement regarding site choice for body temperature measurement requires further instruction or clarification? A. "Although oral temperatures are accessible and convenient, they are inaccurate if the client has just smoked or eaten." B. "Rectal thermometers are a reliable measurement even in the presence of stool." C. "Temporal artery measurements are safe, noninvasive, and very fast." D. "Tympanic membrane readings are readily accessible, reflect the core temperature, and are very fast."
B- Rationale: Document the respiratory rate, depth, rhythm, and character on the appropriate record. Arterial blood gases are not generally documented as part of the postprocedure assessment of respirations (option 4).
A nurse is documenting the respiratory assessment on a client who has just undergone a bronchoscopy. In addition to the respiratory rate, which components should be included in the nurse's note? A. Character of respirations B. Depth, rhythm, and character of respirations C. Rhythm of respirations D. Arterial blood gases, rhythm and depth of respirations
A, D,E- Suction should be applied only while the catheter is withdrawn. Endotracheal suctioning requires surgical asepsis, so the catheter should not be reused (unless an inline suctioning system is in place). To prevent hypoxemia, each suctioning session is limited to two to three attempts. Suctioning should be performed only when indicated, not on a routine basis.
A nurse is preparing to perform endotracheal suctioning for a client. Which of the following are appropriate guidelines to be followed? (Select all that apply.) A. Apply suction while withdrawing the catheter. B.Perform suctioning on a routine basis, every 2 to 3 hr. C.Maintain medical asepsis. D. Use a new tube each time suctioning is performed. E. Limit suctioning to two to three attempts.
A.-Rationale: An average pulse rate for a teenager is 75, not 100, beats per minute. An average heart rate of 100 beats per minute would describe a child between the ages of 5 and 8. An average range of respirations for a newborn is 30 to 80 breaths per minute (option 2). An average pulse range for a 1-year-old is 80 to 140 beats per minute (option 3). An average respiration rate for an older adult is 16 breaths per minute (option 4).
A nurse is teaching a group of nursing students the differences in pulse and respiration readings across the life span. Which statement, if made by a nursing student, indicates the need for further teaching? A. "An average pulse rate for a teenager is 100 beats per minute." B. "An average range of respirations for a newborn is 30 to 80 breaths per minute." C. "An average pulse range for a 1-year-old is 80 to 140 beats per minute." D. "An average respiration rate for an older adult is 16 breaths per minute."
B- A nurse on a medical-surgical unit has been assigned to care for four clients. Which of the following clients is at risk for fluid volume excess (hypervolemia)? A. A client who is receiving a high-ceiling loop diuretic. B. A client who has heart failure. C. A client who lost 500 mL of blood during surgery. D. A client who is 4 hr postoperative and is receiving nasogastric suction. A client who has heart failure is at risk for fluid retention and fluid volume excess. The other clients are at risk for hypovolemia.
A nurse on a medical-surgical unit has been assigned to care for four clients. Which of the following clients is at risk for fluid volume excess (hypervolemia)? A. A client who is receiving a high-ceiling loop diuretic. B. A client who has heart failure. C. A client who lost 500 mL of blood during surgery. D. A client who is 4 hr postoperative and is receiving nasogastric suction.
C- The application of a condom catheter is a noninvasive, routine procedure that can be delegated to an AP. It would be inappropriate to delegate the feeding of a client who has aspiration pneumonia because the client is at risk for further aspiration. Reinforcing teaching should be done by either the RN or LPN. The application of a sterile dressing should also be completed by an RN or LPN.
A nurse on a medical-surgical unit has received change-of-shift report and has been assigned to care for four clients. Which of the following client's needs may be assigned to an assistive personnel (AP)? A. Feeding a client who was admitted 24 hr ago with aspiration pneumonia B. Reinforcing teaching for a client who is learning to walk using a quad cane C. Reapplying a condom catheter for a client who has urinary incontinence D. Applying a sterile dressing to a pressure ulcer
D- Frequent hand hygiene is the best way to prevent the spread of infection. Wearing gloves is appropriate when in contact with any client's blood, body fluids, or nonintact skin, but hand hygiene is still important after removing the gloves. Placing clients with infections in isolation is important for certain types of infections, but it neglects the essential aspect of hand hygiene. Wearing gowns and masks is not necessary if the client's skin is intact.
A nurse teaching a group of personal care assistants should emphasize that the most effective way to decrease the spread of infection is by A. wearing gloves with all clients. B. placing clients with infection in isolation. C. wearing gowns and masks at all times when in contact with a client's skin. D. performing hand hygiene.
D- The RN is responsible for maintaining the PCA pump. Assisting a client to use an incentive spirometer, collecting a clean-catch urine specimen, and providing nasopharyngeal suctioning are within the scope of practice of the LPN.
An RN is making assignments for client care to a licensed practical nurse (LPN) at the beginning of the shift. Which of the following assignments should the LPN question? A. Assisting a client who is 24 hr postoperative to use an incentive spirometer B. Collecting a clean-catch urine specimen from a client who was admitted on the previous shift C. Providing nasopharyngeal suctioning for a client with pneumonia D. Replacing the cartridge and tubing on a patient-controlled analgesia (PCA) pump
B, C- Diabetes mellitus places this client at risk for impaired circulation and immune system function. The client is not at either extreme of the age spectrum, and there is no indication that he is malnourished or that there have been any breaches in aseptic technique during wound care. NCLEX®
An adolescent client who has diabetes mellitus is 2 days postoperative following an appendectomy.The client is tolerating a regular diet well. He has ambulated successfully around the unit with assistance and requests pain medication every 6 to 8 hr while reporting pain at a 2 on a scale of 0 to10 after the medication is given. His incision is approximated and free of redness with scant serous drainage noted on the dressing. Which of the following risk factors for poor wound healing does this client have? (Select all that apply.) A.Extremes in age B. Impaired circulation C. Impaired/suppressed immune system D. Malnutrition E. Poor wound care such as breaches in aseptic technique
C- Sanguineous drainage is bright red and the result of active bleeding. A watery appearance is characteristic of serous or serosanguineous drainage. Green-tinged or yellow and foulsmelling are characteristics of purulent drainage.
An entry in a client's chart states the wound drainage is "sanguineous." That means it is A. watery in appearance. B. green-tinged or yellow. C. bright red. D. foul-smelling.
B- The client's limited mobility as a result of the CVA puts her at risk for skin breakdown. She is well-hydrated and nourished, and there are no data to indicate that she has urinary or fecal incontinence.
Scenario: An older adult client who has diabetes mellitus must now use a wheelchair after a cerebrovascular accident (CVA) 2 years ago that affected her right side. She does not respond to pain on the right side of her body. Her fluid and food intake is good, but she needs help with eating. 6. Which of the following risk factors for developing pressure ulcers does this client have? A. Dehydration B. Limited mobility C. Nutritional impairment D. Incontinence
B- An increase in incisional pain is a sign of a possible wound infection. With infection, the pulse rate and WBC count increase. Increased thirst has many possible causes and does not necessarily indicate an infectious process.
Scenario: An older adult woman is 6 days postoperative following surgery for a bowel obstruction. During the last 24 hr, she has reported nausea, and she vomited small amounts of clear liquid three times in the last 8 hr. Her vital signs are stable. Currently, her incision is well approximated and free of redness, tenderness, and swelling. 4. Which of the following findings would indicate development of a wound infection? A. Decreased pulse rate B. Increased pain C. Decreased WBC count D. Increased thirst
A- Nasogastric tubes are used short-term and can be inserted through the nose. Insertion of a gastrostomy or jejunostomy tube is done by a surgical procedure, and a percutaneous endoscopic gastrostomy (PEG) tube is inserted endoscopically. Surgical and endoscopic insertion presents an increased risk for injury and infection; therefore, they are only indicated for long-term use.
The enteral access tube best suited for short-term use (less than 4 weeks) is a A. nasogastric tube. B. gastrostomy tube. C. jejunostomy tube. D. PEG tube.
B- The greatest risk to the client receiving enteral feedings is injury from aspiration. Therefore, the priority nursing assessment before initiating an enteral feeding is to determine proper place of the tube. Assessing the client's level of consciousness, the presence of any complications of tube feeding (diarrhea), and the freshness of the formula are important but are not the highest priority for this client.
The highest priority nursing assessment before initiating an enteral feeding is determining A. if the client is alert and oriented. B. that the tube is correctly placed. C. how long the feeding container has been open. D. if the client has diarrhea.
A- Rationale: The arm should be at the level of the heart and not above the level of the heart. An arm at shoulder level gives an erroneously low reading. Option 2 describes the correct height for the arm while taking blood pressure. Waiting 1 to 2 minutes before repeating an assessment prevents an erroneously high systolic or low diastolic reading (option 3). Assessing immediately after a meal or while a client smokes can also cause an erroneously high blood pressure, so resting before measuring is the correct technique (option 4).
The nurse is assessing the student's skill set in taking blood pressures. Which observation, if made by the nurse, requires intervention so that the student takes proper measurements? A. The student nurse has the client hold his arm out from his body at shoulder level while taking the reading. B. The student nurse has the client place his arm at the level of the heart while taking the reading. C. The student nurse allows 1-2 minutes between readings if unsure of the numbers. D. The student nurse allows the client to rest after finishing eating before taking a blood pressure.
D- It is essential to encourage and help the client alter her position every 15 min while seated to prevent sustained pressure on any skin areas. While in bed, the head of the client's bed should be elevated no more than 30° to prevent skin breakdown from shearing forces in the sacral area. Donut-shaped cushions increase pressure on the sacral area. A gel foam or air cushion would be a better choice.
Which of the following can the nurse do to prevent skin breakdown? A. Massage the client's bony prominences frequently. B. Keep the client in high-Fowler's position while in bed. C. Have the client sit on a donut-shaped cushion. D. Encourage repositioning every 15 min while the client is in the wheelchair.
DRationale: In this instance, the nurse needs an accurate assessment of the pulse rate and rhythm before administering a medication that affects heart rate, digoxin, so an apical pulse needs to be auscultated for a full minute prior to administration because it is the most accurate means of assessing the pulse. Options 1, 2, and 3 are incorrect because peripheral pulse assessment is less accurate than apical pulse assessment. -
The nurse is preparing to take a pulse on a client who is receiving digoxin (Lanoxin), which affects the heart rate. This assessment needs to be completed prior to the medication administration. Which skill is correct when assessing the pulse of this client? A. A radial pulse taken for 15 seconds B. A femoral pulse taken for 30 seconds C. A carotid pulse taken for a full minute D. An apical pulse taken for a full minute
D- Rationale: Release the valve on the cuff carefully so that the pressure decreases at the rate of 2 to 3 mmHg per second. If the rate is faster or slower, an error in measurement may occur. The client should be positioned appropriately. The adult client should be sitting unless otherwise specified. Both feet should be flat on the floor. Sitting with legs crossed at the knee results in elevated systolic and diastolic blood pressures (option 1). Wrap the deflated cuff evenly around the upper arm. Locate the brachial artery and apply the center of the bladder directly over the artery (option 2). Pump the cuff until the sphygmomanometer reads 30 mmHg above the point where the brachial pulse disappeared (option 3).
The nurse is teaching a nursing student about blood pressure measurement. Which statement, if made by the nursing student, demonstrates the need for further teaching? A. "If the client is sitting in a chair, I should make sure that both feet are flat on the floor." B. "After I locate the brachial artery, I should wrap the deflated cuff evenly around the upper arm." C. "I should pump up the cuff until the sphygmomanometer reads 30 mmHg above the point where the brachial pulse disappeared." D. "After I hear the first heart sound, I should release the valve on the cuff rapidly so as not to injure the client."
A- Tape from the client's nose to the nasogastric tube secures the placement. Safety pins pose a risk for piercing the tubing. The tubing is too bulky to create a loop. Applying tape to the connection of the nasogastric tube and suction tubing does not secure the tube.
The proper way to secure a nasogastric tube is to apply A. tape from the client's nose to the nasogastric tube. B. a safety pin through the nasogastric tube to the client's gown. C. tape to the client's cheek with a short length of tubing looped on the nose. D. tape around the connection of the nasogastric tube and the suction tubing.
C- Flushing the tube after the feeding has been given helps maintain patency by clearing any excess formula from the tube. If the client requires additional fluids, the small amount used for flushing will not be adequate. If formula is to be diluted, it should be done before instilling the feeding. Flushing the tube does not maintain placement of the tube.
The purpose of flushing a tube after an enteral feeding is given is to A. provide adequate fluid intake. B. dilute the concentration of the formula. C. clear the tubing to prevent clogging. D. ensure that the placement of the tube is maintained.
B- A high-fiber diet promotes normal bowel elimination. The choice of fruit and toast is the highest fiber option. Macaroni and cheese, beef tips and noodles, and mashed potatoes and gravy are lower-fiber options.
Which of the following foods should a nurse encourage for a client who is experiencing constipation? A. Macaroni and cheese B. Fresh fruit and whole wheat toast C. Beef tips and noodles D. Mashed potatoes and gravy
B, E- The best position for the client during respiratory assessment is semi-Fowler's with the chest visible. Observing for one full respiratory cycle before starting to count assists in obtaining an accurate count. If the rate is regular, count for 30 seconds and multiply by 2. Count the rate for 1 full min if irregular, faster than 20/min, or slower than 12/min. It is difficult to measure either the respiratory rate or the pulse accurately if counted simultaneously. The respiratory rate is not auscultated with a stethoscope.
Which of the following interventions are appropriate when assessing a client's respirations? (Select all that apply.) A Count the respiratory rate for 1 min. B Place the client in semi-Fowler's position. C Count the respiratory rate simultaneously with the pulse. D Position the stethoscope on the anterior chest. E Observe one full respiratory cycle before counting the rate.
C- Placing a mask on the client prevents contamination of the surgical wound during the dressing change. It would be difficult for the nurse to maintain a sterile field on the far side of the room away from the bedside. The client may be unable to refrain from coughing and sneezing during the dressing change. Keeping tissues close by for the client to use still allows contamination of the surgical wound.
When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. When preparing the sterile field, it is important that the nurse A. keep the sterile field on the far side of the client's room away from the bedside. B. instruct the client to refrain from coughing and sneezing during the dressing change. C. place a mask on the client to limit the spread of micro-organisms into the surgical wound. D. keep a box of tissues nearby for the client to use during the dressing change.
A- Rationale: Apply the sensor and connect it to the pulse oximeter. Make sure the LED and photodetector are accurately aligned, that is, opposite each other on either side of the finger, toe, nose, or earlobe. It may be necessary to remove dark nail polish because it can interfere with accurate measurements (option 2). Inspect and move or change the location of an adhesive toe or finger sensor every 4 hours and a spring-tension sensor every 2 hours (option 3). Compare the pulse rate indicated by the oximeter to the radial pulse periodically. A large discrepancy between the two values may indicate oximeter malfunction or poor perfusion to the area measured by the oximeter (option 4).
Which action performed by the nurse demonstrates proper measurement of oxygen saturation? A. The nurse ensures that the LED and photodetector face each other. B. The nurse uses the finger for a pulse oximetry reading on a client with dark nail polish. C. The nurse moves the spring sensor on the client's finger every 12 hours. D. The nurse documents the pulse rate daily using only the oximeter.
A,C,D- It is important to maintain privacy during catheterization to preserve the client's dignity. Insertion of a urinary catheter requires surgical asepsis, because the catheter is entering a sterile body cavity. Positioning the client supine with knees bent and apart facilitates insertion of the catheter. It is not necessary to darken the room. Talking will not contaminate the sterile field, so it is not necessary to ask the client not to talk.
Which of the following interventions is appropriate when a nurse performs a catheterization on a female client? (Select all that apply.) A Provide privacy. B Darken the room. C Maintain surgical asepsis throughout the procedure. D Position the client supine with knees bent and apart. E Ask the client not to talk during the procedure.
A- A burn has loss of tissue, and the skin edges are not together. A fractured bone and sprained ankle are injuries to underlying structures and do not require healing of the skin. A sutured surgical incision heals by primary intention. NCLEX®
Which of the following is an example of a wound or injury healing by secondary intention? A. An open burn area B. A bone fracture that is casted C. A sprained ankle D. A sutured surgical incision
A,B,E- A client who has diabetes mellitus is at increased risk for infection and should inspect the feet daily. The client should also use moisturizing lotions (but not between the toes) to help keep the skin smooth and supple. Shoes should be checked for foreign objects because decreased sensation may prevent the client from feeling an object or a rough area of the shoe that can cause an injury. The feet should be washed with warm water and dried thoroughly. Over-the-counter products often contain harmful chemicals that can cause skin impairment.
Which of the following are appropriate teaching measures related to care of the feet for a client who has diabetes mellitus? (Select all that apply.) A. Inspect the feet daily. B. Use moisturizing lotions on the feet. C Wash the feet with warm water and let them air dry. D Use over-the-counter products to treat abrasions. E Check shoes for any foreign objects.
A,B,E- Nail polish, inadequate peripheral circulation, and edema can all generate a low reading. Hypothermia rather than hyperthermia and decreased hemoglobin level rather than increased hemoglobin level can result in a low reading.
Which of the following can cause a low pulse oximetry reading? (Select all that apply.) A Nail polish B Inadequate peripheral circulation C.Hyperthermia D. Increased hemoglobin level E. Edema
A- The first voiding of the 24-hr urine specimen is discarded, and the time is noted. All voidings are collected after that and kept in a container on ice. If a urinalysis is ordered, ask the client to urinate and pour the urine into a specimen container. If a culture is ordered, ask the client to urinate first into the toilet, then stop midstream, and finish urinating in the specimen container. The specimen for a 24-hr collection is stored on ice. NCLEX®
Which of the following nursing interventions is correct when performing a 24-hr urine specimen test? A. Discard the first voiding. B. Keep all voidings in a container at room temperature for 24 hr. C. Ask the client to urinate and pour the urine into a specimen container. D. Ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container. The first voiding of the 24-hr urine specimen is discarded, and the time is noted. All voidings are collected after that and kept in a container on ice. If a urinalysis is ordered, ask the client to urinate and pour the urine into a specimen container. If a culture is ordered, ask the client to urinate first into the toilet, then stop midstream, and finish urinating in the specimen container. The specimen for a 24-hr collection is stored on ice. NCLEX®
B- A Venturi mask incorporates an adaptor that allows a precise amount of oxygen to be delivered. The other oxygen delivery systems deliver an approximated amount of oxygen
Which of the following oxygen delivery systems should be used when a precise amount of oxygen needs to be delivered? A. Nonrebreather mask B. Venturi mask C. Nasal cannula D. Simple face mask A Venturi mask incorporates an adaptor that allows a precise amount of oxygen to be delivered. The other oxygen delivery systems deliver an approximated amount of oxygen
B- The most natural and efficient way to urinate is while sitting upright. Left lateral Sims' and right lateral positions are not appropriate for urine collection. The supine position makes it difficult to empty the bladder completely. NCLEX®
Which of the following positions promotes a client's normal elimination? A. Left lateral Sims' B. Sitting C. Supine D. Right side-lying
C,D,E- A sterile item can touch another sterile item without contaminating it. To maintain the sterility of an item, it must stay above the waist, and surgical asepsis is also called "sterile technique." If the nurse turns her back on the sterile field, the sterile field is considered contaminated. The nurse should step away but continue to face the sterile field. The 1-in edge around a sterile field is not considered sterile.
Which of the following statements about surgical asepsis and a sterile field are correct? (Select all that apply.) A.The nurse should turn her back on the sterile field if she needs to cough. B.The 1-inch edge around a sterile field is also considered sterile. C. A sterile item can touch another sterile item without contaminating it. D. Sterile items must remain above the waist. E. Surgical asepsis is also called "sterile technique."
D- A stage III ulcer may extend past all the layers of skin and subcutaneous tissue to the muscle. A stage III ulcer may extend past all the layers of skin and subcutaneous tissue to the muscle. Reddened skin that does not blanch is characteristic of stage I. An abrasion or a blister is seen with stage II. Exposed bone is characteristic of stage IV.
Which of the following statements describes a stage III pressure ulcer? A. The skin is reddened and does not blanch with pressure. B. The ulcer is an abrasion or a blister. C. The bone is exposed at the center of the ulcer. D. The ulcer extends past the subcutaneous tissue to the muscle. A stage III ulcer may extend past all the layers of skin and subcutaneous tissue to the muscle. Reddened skin that does not blanch is characteristic of stage I. An abrasion or a blister is seen with stage II. Exposed bone is characteristic of stage IV. NCLEX® Connection: Reduction of Risk Potential, System Specific Assessment
A, C, D- Unless the client is unstable, UAP can take initial vital signs on a newly admitted client or a client returning from dialysis (options 1 and 3). Measurement of a client's temperature can be delegated to UAP (option 4). The UAP may not assess, and the nurse needs to assess the apical pulse for rhythm and rate. While the UAP can count the rate, they cannot assess for regularity. However, remember that the UAP can do this data collection, but an assessment needs to be completed by a registered nurse (option 2). UAP cannot be delegated vital signs for unstable clients (option 5).
Which of the following tasks can be delegated to unlicensed assistive personnel (UAP)? Select all that apply. A. Vital signs for a client just admitted to the floor from a nursing home B. A client who needs an apical pulse checked prior to medication administration C. Vital signs for a client just returned to the floor from dialysis D. A client who needs a tympanic temperature taken E. Blood pressure for a client whose last two BPs were 98/72 and 85/60
A- To maintain a sterile field, the nurse can only touch other sterile items when wearing sterile gloves without causing contamination. Touching an object on the bedside stand, touching the client's gown, and holding any sterile object below the waist makes the sterile field no longer sterile.
While wearing sterile gloves, a nurse can touch any A. object on the sterile field. B. object on the bedside stand. C. part of the client's gown. D. sterile object below the waist.
