Prof Nursing: Exam 2 Lab skills quizzes

What instruction would the nurse give the client before removing an indwelling urinary catheter?

"Take several slow, deep breaths." Rationale: The nurse would ask the client to take several slow, deep breaths when pulling out the tubing of an indwelling catheter. Slow, deep breathing helps to relax the sphincter muscles.

The nurse is caring for a 72-year-old male client who requires insertion of an indwelling urinary catheter. What is an important assessment question for the nurse to ask the client prior to the procedure?

"Do you have a history of prostate problems?" Rationale: Prostate enlargement usually begins around age 50 and could affect insertion of the indwelling urinary catheter. This would be important for the nurse to know prior to the procedure. A history of urinary tract infections would not affect the procedure of catheter insertion, as sterile technique should be used at all times. A history of abdominal pain or diabetes should not have any bearing on the procedure itself.

While performing client assessment, the nurse notes urine leaking around the indwelling catheter of a male client. The nurse tells the client that the catheter will need to be placed. The client asks why it cannot "just be repositioned." What is the best response by the nurse?

"Repositioning the catheter could cause damage to the urethra or prostate." Rationale: Repositioning the catheter could cause damage to the urethra or prostate and, thus, the catheter should be replaced. By merely telling the client that a new catheter is "needed or better" does not given an adequate explanation. The nurse should not try repositioning the client first, because this will not adequately address the problem.

The nurse is caring for a male client who requires insertion of an indwelling urinary catheter. The client is quite anxious about the procedure and asks the nurse what he can do during the procedure to help it go more smoothly. What is the best response by the nurse?

"Taking deep breaths and bearing down during the procedure may make passage of the catheter through the urethra easier." Rationale: By instructing the client to take deep breaths and bear down during the procedure, the passage of the catheter through the urethra may be easier. The nurse should insert the catheter with a steady motion but should not try to insert it as quickly as possible to avoid urethral damage. Telling the client "not to think about it" or that "most people" do fine devalues the client's fears instead of helping to alleviate them.

The nurse is inserting normal saline into the lumen of a central venous access device (CVAD) prior to obtaining a blood sample. What recommended amount of saline should the nurse use to flush the line? -10 to 15 mL -15 to 20 mL -1 to 5 mL -5 to 10 mL

-5 to 10 mL Rationale: The nurse should insert 5 to 10 mL of normal saline into the lumen to flush the CVAD. This helps to ensure the collection of a fresh blood sample. Less than 5 mL is inadequate to ensure a fresh sample. More than 10 mL is unnecessary.

The nurse is collecting a blood sample from a central venous access device (CVAD). How much blood should the nurse collect in the discard tube? -5 mL -2 mL -1 mL -4 mL

-5mL Rationale: The nurse should collect at least 5 mL in the discard tube to ensure a clean blood sample. Discarding any amount less than 5 mL may result in a contaminated blood sample.

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

-A precut 4 × 4 sterile drain sponge Rationale: 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.

The nurse is caring for a client who is receiving total parenteral nutrition. While changing the dressing of the client's central venous access device (CVAD), the nurse cleanses the site with chlorhexidine. Which action would the nurse perform next? -Apply skin protectant to the same area, applying it directly on insertion site. -Apply skin protectant to the same area, avoiding direct application to the insertion site. -Apply the transparent site dressing or securement/stabilization device over the insertion site. -Wipe or blot the area with a sterile gauze pad and allow it to dry completely.

-Apply skin protectant to the same area, avoiding direct application to the insertion site. Rationale: After cleansing the site with chlorhexidine, the nurse would allow the site to dry completely without wiping or blotting the area. The nurse would then apply skin protectant to the same area, while avoiding direct application to the insertion site, and allow it to dry. Skin protectant improves adhesion of the dressing and protects the skin from damage and irritation when the dressing is removed. After applying skin protectant, the transparent site dressing or securement device would be placed over the insertion site.

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? -Gently pull the dressing material off the client's skin and observe for irritation. -Use an alcohol based adhesive remover to aid in removal of the dressing. -Apply sterile saline to loosen the dressing material from the skin. -Administer an analgesic to the client and warn the client this may be a little painful.

-Apply sterile saline to loosen the dressing material from the skin. Rationale: 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, drawing a blood sample from a client's central venous access device (CVAD), is unable to start the blood flow, despite trying a new specimen tube. What would the nurse do next to try to start blood flow? -Flush the tubing with saline solution. -Ask the client to raise the arm and cough. -Encourage the client to place the arm below the level of the heart. -Flush the lumen with heparin.

-Ask the client to raise the arm and cough. Rationale: If blood does not start flowing when drawing blood from a CVAD, the first action is to try a new specimen tube, because these tubes may be defective. If the new tube does not work, having the client raise the arm above the head and giving a cough will often start the flow. Flushing with either heparin or saline would alter the blood specimen and should not be done. Placing the arm below the level of the heart is not effective for starting blood flow.

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? -Change the dressing surrounding the drain. -Document the decrease in drainage. -Assess for any kinks in the tubing. -Increase the suction to the drain

-Assess for any kinks in the tubing. Rationale: 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 removing the dressing from an abdominal surgical wound during wound care and notices that the wound edges are not intact, there are multiple staples on the dressing, and the surrounding tissue is red with purulent drainage. The chart reports that the incision was clean and dry with the approximated edges and staples intact upon the last assessment. What would be the first recommended nursing intervention in this situation? -Place the client in a sitting position to reduce pressure on the abdomen. -Assess for pain, shortness of breath, and abdominal pressure. -Leave the wound open and notify the health care provider. -Tell the client that this is a life-threatening situation and that the health care provider will be called.

-Assess for pain, shortness of breath, and abdominal pressure. Rationale: When excessive drainage appears on the dressing, the nurse would first assess the client for pain, shortness of breath, and abdominal pressure, and then place the client in the supine position to reduce pressure on the abdomen. The nurse would then place a dry, sterile dressing on the wound site and assess vital signs, while reassuring the client that while the wound condition has changed, he/she is all right and the health care provider will be notified immediately.

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

-Assessing the need for analgesia Rationale: 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.

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

-Below the level of the wound. Rationale: 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 has just removed an indwelling catheter from a client. Which common complications of urinary function should the nurse monitor for in the client, after removal of an indwelling catheter? Select all that apply.

-Burning or irritation while voiding , -Urinary retention , -Difficulty voiding Rationale: The client may experience burning or irritation the first few times he or she voids after removal, due to urethral irritation. If the catheter was in place for more than a few days, decreased bladder muscle tone and swelling of the urethra may cause the client to experience difficulty voiding or an inability to void. The nurse should monitor the client for urinary retention. Urinary frequency, urinary incontinence, and increased volume of urine output are not complications of urinary function following removal of an indwelling catheter.

When preparing to change the dressing of a multiple lumen central venous access device (CVAD), which action does the nurse take to prevent air embolism? -Place the client in an upright position -Clamp each lumen -Put on sterile gloves -Flush each lumen with 10 milliliters normal saline

-Clamp each lumen Rationale: The nurse would clamp off each lumen to prevent air from entering the catheter and causing an air embolism. Sterile technique is used to prevent infection. Flushing the lumens with normal saline solution verifies patency. Placing the client flat, with the arm below the level of the heart reduces the risk of air embolism.

The nurse is collecting a blood sample from a client's central venous access device (CVAD). The nurse notices that the flow stops when drawing the blood, even after changing the specimen tube and having the client cough. What would be the next recommended intervention? -Unclamp the tubing, remove the tube and vacutainer, and flush with normal saline. -Clamp the tubing, remove the tube and vacutainer, and flush with heparin. -Unclamp the tubing, remove the tube and vacutainer, and flush with heparin. -Clamp the tubing, remove the tube and vacutainer, and flush with normal saline

-Clamp the tubing, remove the tube and vacutainer, and flush with normal saline. Rationale: If the blood does not flow after changing the specimen tube, the nurse would clamp the tubing, remove the tube and vacutainer, and flush with 5 mL normal saline. The nurse would then redraw a waste sample and attempt to finish collecting the blood sample. Heparin would not be reinstilled, as it would change the viscosity of the blood. It is important to clamp the tubing before removing the tube and vacutainer to prevent air embolism.

The nurse is collecting a wound culture from a client's puncture wound. What is the nurse's first step in the procedure? -Document the procedure. -Obtain the wound culture. -Dress the wound. -Clean the wound.

-Clean the wound. Rationale: To obtain a wound culture, the nurse would first clean the wound, then obtain the wound culture, redress the wound, and document the procedure when complete. Cleaning the wound removes previous drainage and wound debris, which could introduce extraneous organisms into the collected specimen, resulting in inaccurate results.

The nurse is obtaining a wound culture and has removed the old dressing and discarded it, performed hand hygiene and applied fresh gloves. What should the nurse do next? -Dry the wound bed using a sterile sponge. -Assess the drainage for amount, type, color, and odor. -Open the culture tube and apply the swab to the wound bed. -Cleanse the wound with a nonantimicrobial cleanser.

-Cleanse the wound with a nonantimicrobial cleanser. Reationale: After removing the old dressing, discarding it, performing hand hygiene and applying fresh gloves, the nurse should cleanse the wound with a nonantimicrobial cleanser to prevent the culture from being contaminated by extraneous wound debris. The assessment of drainage for amount, type, color, and odor should have happened when the nurse removed the old dressing, because the old dressing is part of that information. The wound bed should be dried after the wound is cleaned, not before, and the nurse should not open the culture tube until the wound is cleansed and patted dry.

When irrigating a client's wound, the nurse pours irrigation solution from the bottle into a sterile container. What is a recommended action for this step in the procedure? -Discard any irrigation solution remaining in the bottle. -Pour the chilled irrigating solution into the irrigation container. -Date and reuse leftover irrigation solution within 24 hours. -Shake the bottle of irrigating solution before pouring.

-Date and reuse leftover irrigation solution within 24 hours. Rationale: After setting up a sterile field, if indicated, the nurse pours the warmed sterile irrigation solution into the sterile container. The nurse should date the solution bottle if any solution is leftover and use it within 24 hours. There is no need to shake the irrigating solution. The irrigating solution may be warmed for use but should never be chilled for use. Any solution remaining may be used, if kept in the sterile container, for up to 24 hours; therefore, the nurse should not discard the remaining solution.

When removing a client's surgical wound dressing, the nurse notes that there is wound separation and rupture. What is the term for this wound complication? -Sinus tract. -Dehiscence. -Undermining. -Ecchymosis.

-Dehiscence. Rationale: Dehiscence is the term for the accidental separation of wound edges, especially a surgical wound. Ecchymosis is discoloration of an area resulting from the infiltration of blood into the subcutaneous tissue. A sinus tract is a cavity or tunnel underneath a wound that has the potential for infection, and undermining occurs when there are areas of tissue destruction underneath intact skin along the margins of a wound.

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? -Document the presence and location of the safety pin. -Remove the safety pin and clean with an antiseptic preparation. -Obtain a wound culture to test for possible infection. -Notify the health care provider of the finding at the incision site.

-Document the presence and location of the safety pin. Rationale: 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.

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

-Every 4 hours Rationale: 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.

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? -Every 4 hours -Every 2 hours -Every 8 hours -Every hour

-Every 4 hours Rationale: 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 has collected a blood sample from a client's central venous access device (CVAD). After removing the vacutainer, what should the nurse do next? -Flush the line with heparin. -Flush the line with normal saline. -Label the blood sample tube. -Flush the line with sterile water.

-Flush the line with normal saline. Rationale: After collecting the blood and removing the vacutainer, the nurse should flush the line first with normal saline, then with heparin. The line is not flushed with sterile water and the blood sample tube is labeled after flushing the line.

The nurse is positioning a client with a pressure injury to prepare to irrigate the wound. How would the nurse direct the flow of irrigation solution over the wound? -From the left side of the wound to the right side -From the upper end of the wound to the lower end -From the lower end of the wound to the upper end -From the right side of the wound to the left side

-From the upper end of the wound to the lower end Rationale: The nurse would position the client's wound so that the irrigation solution would flow from the upper end of the wound to the lower end. In this way, gravity directs the flow of the liquid from the least contaminated area of the wound to the most contaminated area, thereby decreasing the risk of wound contamination. Directing the flow of irrigating solution from the lower end to the upper end, or from one side to the other side, does not ensure that the solution flows from the least contaminated area to the most contaminated area.

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

-Fully compress the bulb and reapply the cap. Rationale: 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 has emptied the drainage from a Hemovac drain. How will the nurse re-establish the suction?

-Fully compress the drain and reapply the cap. Rationale: 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.

When irrigating an infected wound, which action by the nurse best helps to prevent contamination of the irrigation syringe? -Cleaning the tip of the syringe with an alcohol wipe after each use -Directing the flow of irrigating solution from the top of the wound -Keeping the tip of the syringe at least 1 in (2.5 cm) above the wound -Positioning the client to face away from the sterile supplies

-Keeping the tip of the syringe at least 1 in (2.5 cm) above the wound Rationale: The best way to prevent contamination of the irrigation syringe is to ensure it never comes in contact with the wound by keeping the tip of the syringe at least 1 in (2.5 cm) above the wound when irrigating the wound. Although the nurse should direct the flow of irrigation from the top of the wound downward, this is not to prevent contamination of the syringe. Positioning of the client is based on wound location not on preventing contamination of the syringe. Cleaning the tip with alcohol wipe after each use is not a recommended way to keep the syringe free of contamination.

When collecting a culture from a client's wound, according to evidence-based practice, which type of motion will the nurse use when applying the swab to the wound tissue to obtain the most accurate results? -Pushing motion -Up-and-down motion -Back-and-forth motion -Rolling motion

-Rolling motion Rationale: The nurse would insert the swab into the wound and gently roll it over the wound surfaces to obtain a sample of the pathogens causing the infection. Using a pushing motion, up-and-down motion, or back-and-forth motion will not provide the most accurate results according to evidence-based practice and may actually cause injury to the wound tissues.

When changing the dressing of a central venous access device (CVAD), how should the nurse remove the old dressing? -Lift it proximally, and then work distally while stabilizing the catheter with an antimicrobial swab. -Lift it distally, and then work proximally to the insertion site while stabilizing the catheter with the gloved finger of the nondominant hand. -Pull it up from the top to the bottom, applying pressure to the catheter with a gauze pad. -Pull it up from the bottom to the top, applying pressure to the catheter with an antimicrobial swab.

-Lift it distally, and then work proximally to the insertion site while stabilizing the catheter with the gloved finger of the nondominant hand. Rationale: When changing the dressing, the nurse would remove the old dressing by lifting it distally and then working proximally, making sure to stabilize the catheter with the gloved finger (clean gloves) of the nondominant hand. These steps help to maintain aseptic technique during the procedure. The gloved finger provides more stability to the catheter than an antimicrobial swab.

The nurse is planning to replace a client's wound dressing. The deep wound bed is to remain moist and requires packing. Which action is appropriate? -Loosely pack the dampened dressing material to prevent too much pressure on the wound bed. -Instill 50 mL of normal saline into the wound and loosely cover with packing material. -Fill the wound with sterile saline gel and cover with a large transparent dressing. -Insert rolled gauze into the wound; saturate it with povidone-iodine solution and cover with a moisture-impervious dressing.

-Loosely pack the dampened dressing material to prevent too much pressure on the wound bed. Rationale: Gently press to loosely pack the moistened gauze into the wound. Avoid overpacking the gauze; loosely pack to prevent too much pressure in the wound bed, which could impede wound healing. The nurse should not instill normal saline or fill the wound with sterile saline gel, as these will not be effective in keeping the wound moist. Inserting rolled gauze into the wound will likely put too much pressure on the wound bed.

The nurse is caring for a client with an abdominal wound and prescriptions from the health care provider. Which prescription will the nurse initiate first? -Consult dietician to assist client with meal choices -Obtain a sterile wound culture -Assist client up to chair three times daily -Give ciprofloxacin 1gram IV every 12 hours

-Obtain a sterile wound culture Rationale: The nurse should first obtain the sterile wound culture. The culture should be obtained as soon as possible, because it takes time for the results to return and must be done before the nurse can start the ciprofloxacin. Antibiotics interfere with microorganism growth and the primary reason for obtaining a culture is to identify the cause of the infection. Identifying the invading microorganisms helps to determine treatment options and select the most appropriate treatment. The culture should be obtained while the client is in bed; therefore, it should be done before assisting the client up to a chair. Consulting the dietician to assist the client with meal choices should wait until the culture is obtained and the antibiotic is started, because it is of less importance to the well-being and safety of the client.

The nurse has finished cleaning a client's surgical wound. What would be the nurse's next action in this procedure? -Pat the wound dry with a sterile gauze sponge. -Allow the wound to air dry for 2 minutes. -Measure the length, depth, and width of the wound. -Position the client to promote drainage of the solution.

-Pat the wound dry with a sterile gauze sponge. Rationale: The next step after cleaning a client's wound is to dry the wound with a sterile gauze sponge in the same manner in which it was cleaned, moving from top to bottom and from the inside to the outside of the wound. Moisture provides a medium for the growth of microorganisms. The nurse should not air dry the wound but pat it dry with a sterile gauze. Measuring the wound should happen after removing the old dressing. At that time the nurse should assess the wound, wound bed, drainage, and measure the wound. Positioning of the client should happen before beginning the procedure.

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? -T-tube drain -Hemovac drain -Jackson-Pratt drain -Penrose drain

-Penrose drain Rationale: 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 collecting a wound culture from a client from two different sites. Which actions should the nurse take while performing this procedure? Select all that apply. -Use the same swab for both wound sites. -Tap the outside of the culture tube with the swab before placing it in the tube. -Press and rotate the swab several times over the wound surfaces. -Place the swab in the culture tube when done. -Insert a swab into the wound. -Touch the swab to the intact skin at the wound edges.

-Press and rotate the swab several times over the wound surfaces. -Place the swab in the culture tube when done. Insert a swab into the wound. Rationale: The nurse should carefully insert the swab into the wound and then press and rotate the swab several times over the wound surfaces. After collecting the specimen, the nurse should place the swab back in the culture tube. The nurse should be careful to keep the swab and the inside of the culture tube sterile at all times. This means that the nurse should avoid touching the swab to intact skin at the wound edges or to the outside of the tube, as this would contaminate both the swab with organisms not in the wound and the areas that the swab touches with organisms found in the wound. A different swab, not the same, should be used for each wound site to prevent cross-contamination.

After removing the dressing of a client's central venous access device (CVAD), the nurse notes dried blood at the catheter insertion site. What is the next action by the nurse? -Put on clean gloves and cleanse the site using a chlorhexidine swab in a back and forth motion for 30 seconds. -Put on sterile gloves and cleanse the dried blood using a sterile antimicrobial wipe in a circular motion beginning at insertion site and working outward. -Put on clean gloves and cleanse the dried blood using a sterile antimicrobial wipe in a circular motion beginning at the insertion site and working outward. -Put on sterile gloves and use a gauze pad to cleanse the dried blood using a circular motion beginning from the outside and working to the insertion site.

-Put on sterile gloves and cleanse the dried blood using a sterile antimicrobial wipe in a circular motion beginning at insertion site and working outward. Rationale: While wearing sterile gloves, the nurse would wipe off any old blood or drainage with a sterile antimicrobial wipe, starting at the insertion site and continuing outward in a circle. Sterile gloves are used after removing the dressing to prevent contamination of the insertion site. Wiping the site from the outside to the inside could introduce microorganisms into the site. The dried blood must be removed before cleansing with chlorhexidine to prevent organisms from being introduced into the tissues.

The nurse is preparing to perform wound care. Which intervention should be implemented to protect the nurse from injury? -Maintain a sterile field. -Gather all necessary equipment. -Position the client. -Raise the bed to elbow height.

-Raise the bed to elbow height. Rationale: The nurse would adjust the bed to a comfortable working position, usually elbow height. Having the bed at the proper height prevents back and muscle strain for the nurse. Maintaining a sterile field prevents risk of infection for the client. Positioning the client is to make the wound accessible for care. Gathering equipment helps the nurse be organized, not prevent injury.

When the nurse is drawing a blood sample from a client's central venous access device (CVAD), the blood stops flowing after the collection tube has been placed. The nurse removes the tube and flushes the lumen with 5 mL of saline solution. What is the next action by the nurse? -Flush with heparin. -Attempt to collect the blood sample. -Notify the health care provider. -Redraw the waste sample.

-Redraw the waste sample. Rationale: After flushing the lumen with 5 mL of saline solution, it would be necessary to redraw a waste sample before attempting to collect the sample. If the waste sample is not drawn at this point, the blood sample may be altered by the saline solution. Flushing with heparin would be done after the sample is collected. It is not necessary to notify the health care provider until all efforts to obtain the sample have been exhausted.

The nurse is caring for a client who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and adheres to the wound bed. Which modification is most appropriate? -Discontinue application of saline-moistened packing and apply a hydrocolloid dressing instead. -Reduce the time interval between dressing changes. -Use less packing material. -Assure that the packing material is completely saturated when placed in the wound.

-Reduce the time interval between dressing changes. Rationale: Allowing the dressing material to dry will disrupt healing tissue. Therefore, the time interval between dressing changes should be reduced to prevent the dressing from drying out. Too much moisture in the dressing may cause maceration. Shortening the time interval between dressing changes is more appropriate than increasing dressing moisture. There is no indication that too much packing material was used. A hydrocolloid dressing in not indicated.

The nurse assesses the surgical dressing of a client who has just arrived from the post-anesthesia care unit (PACU) and observes the dressing has a moderate area of serous drainage on it. What is the best action by the nurse? -Change the dressing using sterile technique -Notify the health care provider of the bleeding -Reinforce the dressing and assess site frequently -Call a rapid response and stay with the client

-Reinforce the dressing and assess site frequently Rationale: Because bleeding is expected during the first 12 to 24 hours after surgery, the best action by the nurse is to reinforce the dressing and assess the site frequently. Because this is the first surgical dressing that was applied by the surgeon, only the surgeon should change the dressing. Bleeding is expected and, therefore, the health care provider does not need to the notified. Calling a rapid response is not needed in this situation.

The nurse is collecting a wound culture and has removed the current dressing and discarded it. What should the nurse do next? -Assess and clean the wound per orders. -Twist and break the seal on the culture tube. -Remove gloves and perform hand hygiene. -Identify the client using two client identifiers.

-Remove gloves and perform hand hygiene. Rationale: After removing the current dressing and discarding it, the nurse should remove the gloves and perform hand hygiene. Then the nurse should apply fresh gloves; sterile gloves may be indicated if the wound edges must be separated to insert the culture swab. After hand hygiene and applying fresh gloves, the nurse would assess and clean the wound using a non-antimicrobial cleanser such as sterile saline, open the culture tube, obtain the culture and complete the procedure. Identifying the client using two client identifiers should happen before the procedure is begun along with explaining the procedure to the client.

The nurse is changing the dressing on a client's surgical wound. After the old dressing is removed, the nurse notices that the client's skin is red and blistered where the dressing had been secured with tape. Which would be an appropriate action by the nurse? -Allow the wound to air dry. -Notify the health care provider for further instructions. -Replace the dressing with a smaller one. -Replace the dressing with a larger one.

-Replace the dressing with a larger one. Rationale: When replacing a dressing that has caused blisters on the underlying skin, the nurse would cleanse the area thoroughly, being careful not to aggravate the reddened and blistered areas, and could place a new, larger dressing over the wound so that the blistered area is not further aggravated by tape.

What are important elements for the nurse to remember regarding proper attachment of an indwelling urinary catheter for a male client? Select all that apply.

-Secure catheter tubing to the client's inner thigh or lower abdomen. , -Place drainage bag below the level of the bladder. , L--leave slack in catheter to ensure ease in client leg movement. Rationale: The catheter tubing should be secured to the client's inner thigh or lower abdomen to prevent pulling. The drainage bag should never be attached to the side rail to prevent pulling. There should be slack left with catheter to ensure ease in client leg movement. By placing drainage bag below the level of the bladder, the flow of urine will be facilitated. The catheter should not be positioned under the leg behind the client to prevent catheter kinking and twisting and to vacillate the unobstructed flow of urine.

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

-Secure the drain to the client's gown below the level of the wound. Rationale: 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.

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? -Apply an abdominal binder over the entire wound and drain to support the site. -Secure the drain to the client's gown with a safety pin below the level of the wound. -Allowed the Jackson-Pratt drain to hang freely to avoid any kinks in the tubing. -Tape the drain to the dressing material securely below the level of the wound.

-Secure the drain to the client's gown with a safety pin below the level of the wound. Rationale: 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 client with a sitz bath. Which actions should the nurse perform? Select all that apply. -Slowly unclamp the tubing and allow the sitz bath to fill. -Insert tubing into the infusion port of the sitz bath. -Ensure that the call bell is within reach. -Have the client soak for about 50 to 60 minutes. -Hang the bag of tepid to warm water at the client's chest height on an IV pole. -Fill the bowl of the sitz bath about halfway full with tepid to warm water.

-Slowly unclamp the tubing and allow the sitz bath to fill. -Insert tubing into the infusion port of the sitz bath. -Ensure that the call bell is within reach. -Fill the bowl of the sitz bath about halfway full with tepid to warm water. Rationale: The nurse should fill the sitz bath about halfway full with tepid to warm water, fill a bag with the same temperature water, insert the tubing from the bag into the infusion port of the sitz bath, and slowly unclamp the tubing and allow the sitz bath to fill completely. Tepid water can promote relaxation and help with edema; warm water can help with circulation. Filling the sitz bath ensures that the tissue is submerged in water. The call bell should be placed within reach because the client may become light-headed due to vasodilation and require assistance. The bag of water should be hung above the client's shoulder height, not at chest level. If the bag is hung lower, the rate of flow will not be sufficient, and water may cool too quickly. The client should be allowed to soak about 15 to 20 minutes, not 50 to 60 minutes.

The nurse is irrigating a client's wound using sterile technique. When directing the irrigating solution into the wound, what does the nurse use to collect the solution? -Sterile basin -Used wound dressing -Waterproof pad -Gauze

-Sterile basin Rationale: When irrigating a client wound, the nurse would place a sterile basin under the wound to protect the client and bed linens from the contaminated solution. The used wound dressing should be immediately discarded after removal and not used to collect solution, because this dressing is contaminated. A waterproof pad would not be used to collect the solution but may be used underneath the basin in case of splashes or spills to prevent soiling the bed linen. Gauze is not used to collect irrigating solution, this would be an expensive choice and does not protect the bed linen.

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? -Hemovac drain -Penrose drain -T-tube drain -Jackson-Pratt drain

-T-tube drain Rationale: 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'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? -Replace the cap on the chamber. -Use a gauze pad to clean the outlet. -Fully compress the chamber. -Put on clean gloves.

-Use a gauze pad to clean the outlet. Rationale: 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.

The nurse is observing an unlicensed assistive personnel (UAP) drawing a blood sample from a client's central venous access device (CVAD). After the collection tube has been placed, the blood stops flowing. Which action by the UAP would require the nurse to intervene? -The UAP replaces the specimen tube. -The UAP flushes the lumen with 5 mL of sterile water. -The UAP clamps the tubing and removes the tube and the vacutainer. -The UAP asks the client to raise the arm and cough.

-The UAP flushes the lumen with 5 mL of sterile water. Rationale: The nurse should intervene if the UAP flushes the lumen with 5 mL of sterile water. When drawing a blood sample from a client's CVAD and blood stops flowing after the collection tube has been placed, the UAP should first replace the specimen tube, because these tubes are sometimes defective. If blood still does not flow, the UAP should ask the client to raise the arm and cough. If additional intervention is still required for starting the blood flow, the UAP should clamp the tubing, remove the collection tube and vacutainer, and 5 mL of saline solution, not sterile water.

The nurse is preparing to clean a client's surgical wound. What would the nurse assess before beginning the procedure? -The client's comfort and effectiveness of pain medication -Any physical limitations the client may have -Color of drainage on the wound dressings -The client's temperature and pulses

-The client's comfort and effectiveness of pain medication Rationale: Prior to cleaning a client's wound, the nurse would assess the client's level of comfort and the need for analgesics before wound care. Wound care may cause pain for some clients. The color of any drainage on wound dressings would be assessed during the wound care procedure. Assessing physical limitations, temperature, and pulses may be appropriate, but these assessments are not directly related to the procedure for cleaning a wound. The procedure for cleaning the wound is the same for a client with or without physical limitations.

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

-The drain will remain patent. -The client does not experience pain or discomfort. -Care is accomplished without contaminating the wound. -Care is accomplished without causing trauma to the wound. Rationale: 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.

During sitz bath therapy, a client reports feeling dizzy and lightheaded. What is the most likely rationale for this occasional effect from sitz bath therapy? -The client's wound has begun bleeding. -The cool water has caused the client to become cold. -The client's blood pressure has increased. -The warm water caused vasodilatation

-The warm water caused vasodilatation. Rationale: Because of the application of warm water to the area, vasodilatation can occur, causing the client to feel dizzy or lightheaded. Because of this occasional effect from sitz bath therapy, the nurse should ensure the client's call bell is in reach and instruct the client to not attempt to stand without assistance. Sitz bath is done with warm water, and the client may become cold if the water is allowed to cool, but this should not cause dizziness or lightheadedness. If the client experiences vasodilatation from the warm water, the vasodilation would cause the blood pressure to decrease slightly, not increase. Bleeding is not a common occurrence from sitz bath therapy and therefore not the most likely reason.

The nurse is collecting a blood sample from a client's central venous access device (CVAD) and notices that the flow stops when drawing the blood. What should the nurse do first? -Try a new specimen tube. -Raise the head of the bed. -Make sure the tubing is clamped. -Push down on the access needle.

-Try a new specimen tube. Rationale: If the flow of blood is slow or stopped, the nurse would first try a new specimen tube, because these tubes are sometimes defective. The tubing is not clamped when drawing a specimen. Pushing down on the access needle and raising or lowering the head of the bed are helpful when meeting resistance in flushing a CVAD.

A nurse needs to obtain blood samples for lab studies to check the electrolyte levels for a client who has a multilumen non-tunneled percutaneous central venous catheter in place. The client is receiving intravenous (IV) fluids through the central venous access device (CVAD). What should be the nurse's first step in this procedure? -Increase the flow of fluids to the CVAD. -Turn off the flow of fluids to the CVAD. -Flush the CVAD with normal saline. -Place the CVAD dial on "hold."

-Turn off the flow of fluids to the CVAD. Rationale: First, the nurse should turn off the flow of fluids to the CVAD, and then wait for the specified amount of time. There is not a "hold" button on the CVAD, and the device is not flushed with normal saline. Increasing the flow of fluids should be inappropriate.

A nurse is assisting a client with the use of a urinal. The nurse recognizes that which statement about the use of a urinal is true?

-Unless contraindicated, nurses should encourage clients to stand to use a urinal. Rationale: A standing position facilitates bladder emptying and decreases the likelihood of spillage of urine. Although female urinals exist, they are more difficult to use and are not commonly used in health care facilities. Replacing urinals every 24 hours is not necessary. A urinal should not be left in place for extended periods of time, because pressure and irritation to the client's skin can result.

The nurse is changing the dressing of a client whose skin has been irritated by the frequent removal of adhesive tape that holds the dressing in place. Which would be a recommended nursing intervention? -Use Montgomery straps instead of adhesive tape to hold the dressing in place. -Cleanse the area with an alcohol wipe prior to applying the new dressing. -Use a skin barrier on the wound itself prior to applying a dressing. -Cleanse the area with an antimicrobial wipe prior to applying the new dressing.

-Use Montgomery straps instead of adhesive tape to hold the dressing in place. Rationale: When a client's skin around a wound has been irritated by frequent removal of tape, the nurse would consider using Montgomery straps, non-allergenic tape, or dressing ties, instead of adhesive tape, to hold the dressing in place. A skin barrier could also be used on the skin around the wound (not on the wound itself). Alcohol wipes or antimicrobial wipes would not be used, as they would further irritate the skin.

The nurse is changing the dressing on a client's surgical wound and notices that part of the dressing is sticking to the underlying skin. What is the recommended nursing intervention in this situation? -Use small amounts of sterile saline to help loosen and remove the dressing. -Soak the area with sterile water using gauze pads. -Wipe the area with an alcohol wipe and pull the dressing from the skin. -Wipe the area with an antimicrobial swab and pull the dressing from the skin.

-Use small amounts of sterile saline to help loosen and remove the dressing. Rationale: If part of the dressing sticks to the skin, the nurse would use small amounts of sterile saline to loosen and remove the dressing. Sterile saline moistens the dressing for easier removal and minimizes damage and pain.

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

-When the drain is one-half to two-thirds full -At least every 4 hours Rationale: 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 is irrigating a client's pressure injury. How would the nurse know when to stop irrigating the wound? -When the solution from the wound flows out clear -When all the irrigation solution is finished -When the solution from the wound flows out a pink color -When the solution from the wound flows out a red color

-When the solution from the wound flows out clear Rationale: The nurse knows to stop irrigating a wound when the solution from the wound flows out clear. The irrigation removes the exudate and debris, which turns the solution from the wound red to pink to clear, when finished. It is not necessary to use all the solution if the flow is clear already. The nurse should not stop when the return flow is red or pink, this color indicates the wound has not been thoroughly cleaned or irrigated yet.

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

-With a safety pin, secure the drain to the client's gown below the wound. Rationale: 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.

The nurse turns off an intravenous (IV) infusion and waits for 1 minute before obtaining a blood sample from the client's central venous access device (CVAD). For what client would this sequence of actions be appropriate? -a client receiving heparin -a client receiving a solution that alters laboratory results -a client receiving total parenteral nutrition (TPN) -a client receiving a standard IV solution

-a client receiving a standard IV solution Rationale: The nurse should turn off an intravenous (IV) infusion and wait for 1 minute before obtaining a blood sample from a client receiving a standard IV solution. The nurse should wait for 5 minutes if the client were receiving heparin, TPN, or any other solution that alters laboratory results.

The nurse is preparing to change the dressing for a client with a peripherally inserted central catheter (PICC). At what point would the nurse assess the insertion site? -when applying the skin protectant -after putting on clean gloves -after removing the old dressing -as the site is being cleaned

-after putting on clean gloves Rationale: The nurse assesses the insertion site of a central venous access device (CVAD) through the old dressing after putting on clean gloves. Care to the site is completed once the old dressing is removed. Site care includes cleaning the site and applying a skin protectant.

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? -Face shield -Mask -Clean gloves -Gown

-clean gloves Rationale: When emptying a Hemovac drain, it would be most essential for the nurse to put on clean gloves to reduce the risk of exposure to blood and body fluids. Gloves prevent the spread of microorganisms. A mask or face shield would be warranted if there is a risk for splashing. A gown would not be needed.

Which client will the nurse expect to be prescribed sitz baths? Select all that apply. -client after childbirth -client after repair of a femur fracture -client who had a hip replacement surgery -client who had rectal surgery -client who had surgery to the perineum

-client after childbirth , -client who had rectal surgery , -client who had surgery to the perineum Rationale: A sitz bath can help relieve pain and discomfort for clients who have had surgeries to the pelvic, perineal, or rectal areas; therefore, the nurse would expect the client who had rectal surgery, the client after childbirth, and the client who had surgery to the perineum to be prescribed sitz bath therapy. The therapy would not be appropriate for a client after hip replacement or repair of a femur fracture.

What should the nurse assess before application of sitz bath therapy? Select all that apply. -client's serum sodium levels -client's ability to sit for 15 to 20 minutes -client's perineal/rectal area -client's ability to ambulate to the bathroom -client's need to void

-client's ability to sit for 15 to 20 minutes -client's perineal/rectal area -client's ability to ambulate to the bathroom -client's need to void Rationale: Before application of sitz bath therapy, the nurse should assess the client's ability to ambulate to the bathroom, ability to sit for 15 to 20 minutes, appearance of the perineal/rectal area for swelling, drainage, tenderness, and the client's bladder fullness and need to void. Electrolyte levels are not affected by sitz bath therapy.

A nurse is preparing to draw a blood sample from a central venous access device (CVAD) that has more than one lumen. Which lumen is most appropriate for the nurse to use to take the sample? -distal -proximal -longest -shortest

-distal Rationale: The nurse should use the distal lumen when drawing blood samples from a CVAD, when possible. The length of the lumen is not a determinant in this decision. The proximal lumen should be used only if the distal lumen is unavailable.

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

-in a circular motion beginning at the pin site and moving outward toward the edge of the wound Rationale: 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.

When evaluating the effectiveness of sitz bath therapy, what outcome will the nurse expect? -decreased need for dressing changes -increased drainage from wound site -increased comfort of client -decreased anxiety of client

-increased comfort of client Rationale: The expected outcome for sitz bath therapy is that the client will verbalize an increase in comfort. Increased drainage, decreased need for dressing changes, and decreased anxiety are not expected outcomes for this type of therapy.

The nurse is applying a condom catheter to an older adult client who has become incontinent of urine following hip surgery. In what position would the nurse place the client when applying this device?

-lying flat Rationale: The nurse would lower the head of the bed, so the client is lying flat on his back. This position allows easy access to the site.

The nurse is caring for a client who has a peripherally inserted central catheter (PICC) in place to receive antibiotics. As the nurse prepares to change the dressing of the PICC, how should the nurse position the client? -sitting upright, with the arm extended from the body over the head -sitting upright, with the arm flexed at the elbow below heart level -lying flat, with the arm extended from the body below heart level -lying flat, with the arm extended from the body above heart level

-lying flat, with the arm extended from the body below heart level Rationale: The nurse would assist the client to a comfortable position that provides easy access to the central venous access device (CVAD) insertion site and dressing. Because this client has a PICC, the nurse would position the client lying flat, with the arm extended from the body below heart level. This position is recommended to reduce the risk of air embolism. Sitting upright does not reduce the risk of air embolism.

The nurse places a frail older adult client on the bedpan. After the client has voided and the nurse has removed the bedpan, what assessment is necessary for the nurse to complete?

-skin assessment of the buttocks and coccyx Rationale The skin of frail older adult clients is very fragile. Sitting on the bedpan can cause pressure and placing the client on the bedpan can cause friction and shear. These movements could cause irritation or skin breakdown. The nurse should assess the skin surrounding the area where the bedpan was placed each time the bedpan has been used. Determining the client's intake is an important assessment, but it is not directly related to the bedpan use. Making sure the client is warm, side rails are up, and the call bell is in place are interventions, not assessments.

After setting up a sterile field and putting on sterile gloves, the nurse prepares to clean a client's surgical wound. Which cleaning technique would the nurse use to prevent contamination of the wound? The nurse cleans the wound from the: -outside to center using a new gauze for each wipe. -distal to proximal using a new gauze for each wipe. -side to side using a new gauze for each wipe. -top to the bottom using a new gauze for each wipe.

-top to the bottom using a new gauze for each wipe. Rationale: The nurse would clean the wound from the top to the bottom and from the center to the outside using a new gauze for each wipe. This method ensures that the cleaning is from the least to the most contaminated area and a previously cleaned area is not contaminated again. Cleaning from outside to center, from side to side, or from distal to proximal increases the risk of contaminating the wound as the nurse is starting in the most contaminated area and cleaning into the wound.

Which would be the best choice of a device for urinary elimination for a 42-year-old male client who is on bed rest following knee surgery?

-urinal Rationale: Male clients confined to bed usually prefer to use a urinal for voiding and the bedpan for defecation. Female clients usually prefer to use the bedpan for both. The bedside commode is appropriate for clients who can be assisted out of bed onto the commode. The fracture bedpan is frequently used for clients with fractures of the femur or lower spine, and very thin or elderly clients.

When applying a condom catheter to a client, how much space would the nurse leave between the tip of the penis and the end of the condom?

1 to 2 in (2.5 to 5 cm) Rationale: When applying a condom catheter, the nurse would leave 1 to 2 in (2.5 to 5 cm) of space between the tip of the penis and the end of the condom. This space prevents irritation to the top of the penis and allows for free drainage of urine.

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.

1)Place the graduated collection container under the drain outlet. 2)Remove the cap from the bulb. 3)Empty the bulb's contents into the collection chamber. 4)Wipe the outlet of the bulb with a sterile gauze pad. 5)Fully compress the bulb. 6)Replace the cap on the bulb. Rationale: 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.

Place in order, from first to last, these actions the nurse will perform when providing wound care to a client with a pressure injury. Use all options.

1)Put on clean gloves. 2)Remove old dressing. 3)Assess the wound bed. 4)Open dressing materials. 5)Irrigate the wound bed. 6)Time and date the dressing. Explanation: The nurse should first put on clean gloves, then remove the old dressing, assess the wound bed and surrounding skin, change gloves, open dressing materials, provide the wound care including irrigating the wound bed, then time and date the dressing once completed.

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.

1)Wipe the outlet with a gauze pad. 2)Compress the chamber. 3)Apply the cap. 4)Check the patency of the equipment. 5)Secure the device to the client's gown. Rationale: 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.

Which client is a greatest risk of developing a pressure injury? -84-year-old client diagnosed with a urinary tract infection who frequently gets out of bed without calling for assistance -25-year-old client on bed rest for 24 hours following a procedure -47-year-old client with severe alcoholism and a traumatic brain injury resulting in unconsciousness -17-year-old client postoperative for fracture of the upper extremity

47-year-old client with severe alcoholism and a traumatic brain injury resulting in unconsciousness Explanation: The 47-year-old client with severe alcoholism (poor nutritional status) and a traumatic brain injury (immobile) is at greatest risk for developing a pressure injury. The 17-year-old does not have any noted risk factors, the 25-year-old is young and only on bedrest for 24 hours so is very unlikely to develop a pressure injury, and the 84-year-old is ambulatory, making them a low risk for a pressure injury. For the 84-year-old client, the greatest risk is for falls.

For which client would using powder on a bedpan be contraindicated?

A client scheduled for a urinalysis using the urine that will be collected. Rationale: The nurse would not use powder on the bedpan of a client scheduled for a urinalysis because it could contaminate the sample. Using powder is not contraindicated for the other clients; however, a client with a pressure ulcer or skin irritation might be uncomfortable using a bedpan.

For which clients would a fracture bedpan be the most comfortable choice for urinary elimination?

A thin, elderly female client with pneumonia. Rationale: Very thin or elderly clients, clients who cannot easily raise themselves, and clients who need to maintain strict body alignment often find it easier and more comfortable to use the fracture bedpan. The fracture pan has a shallow, narrow upper end with a flat wide rim, and a deeper, open lower end. The upper end fits under the client's buttocks toward the sacrum, with the deeper, open lower end toward the foot of the bed. Normally, when confined to bed, females would use a bedpan and males would use a urinal for voiding.

Which client would be at greatest risk for developing a pressure injury? -Adolescent client with a cast on the left leg -Older adult client who has chronic obstructive pulmonary disease (COPD) -Client who is delirious after taking pain medications -Adult client who is comatose

Adult client who is comatose. Explanation: A client who is comatose is at greatest risk for developing a pressure injury due to the inability to turn or move in bed. This client needs to be turned regularly to prevent development of a pressure injury. The other clients have no restrictions for movement and would not be at great risk for developing a pressure injury. An older client who is bedridden (not a factor with COPD) would also be at high risk for developing a pressure injury due to age-related skin alterations.

The nurse is applying a condom catheter to a client who is urinating frequently and unable to control his urination following surgery. Which accurately describes the correct procedure for this application?

Apply the condom sheath securely enough to prevent leakage, but not so tight as to restrict blood flow. Rationale: The nurse would apply the condom catheter securely enough to prevent leakage, but not so tight as to restrict blood flow. This is achieved by rolling the condom sheath outward and leaving space between the tip of the penis and the end of the condom sheath. Applying the catheter too tightly can restrict blood flow and cause unnecessary swelling, skin excoriation, and skin damage. Applying the catheter too loosely can cause leakage of urine onto the client and the client's bedding.

The nurse receives a prescription to remove an indwelling urinary catheter from a client who is pregnant and on bed rest. The nurse should be sure to maintain which safety protocol when performing this procedure?

Clean technique. Rationale: Removal of an indwelling catheter is performed using clean technique. Sterile technique (surgical asepsis) is used when inserting an indwelling catheter. Transmission precautions would be used only in cases where it is indicated. Hand hygiene prevents the spread of microorganisms.

The nurse is preparing a bedpan to use for a client post-abdominal surgery. What is the most important concept that the nurse should remember when assisting a client with a bedpan?

Client dignity. Rationale: Urination is usually a private matter for an individual. Although client safety, comfort, and autonomy are important considerations, when offering a bedpan to a client the most important concept to remember is respect for the client's privacy and dignity.

When assessing a client's skin, the nurse observes an area of deep purple discoloration on the client's heel. The skin in that area is intact. How will the nurse document this finding? -Stage 1 pressure injury -Deep tissue injury -Unstageable, skin intact -Stage 2 pressure injury

Deep tissue injury Explanation: The nurse should document this finding as a deep tissue injury. Deep tissue injuries are characterized by a purple or maroon localized area of discolored intact skin or blood-filled blister caused by damage to underlying soft tissue from pressure and/or shear. The description of stage 1 pressure injury includes intact skin with non-blanchable redness. In a stage 2 pressure injury, the skin would not be intact, and there is partial-thickness skin loss involving epidermis, dermis, or both. An unstageable pressure injury has slough, which is a yellowish stringy substance attached to the wound bed, or eschar, which is black or brown necrotic tissue covering the wound, which prevents knowledge of the depth of the wound.

The nurse meets resistance when inserting a Foley catheter into a client. What would be the recommended action in this situation?

Do not force the catheter. Rationale: If resistance is met when inserting a Foley catheter, the nurse should not force the catheter as this could cause trauma to the structures. The nurse could rotate the catheter ½ turn and try to advance it again. If this does not work, the nurse should notify the health care provider.

When monitoring a client with a condom catheter, the nurse finds that the catheter will not stay on the client. What would be the initial recommended step for this situation?

Ensure that the condom catheter is the right size. Rationale: When the condom catheter will not stay in place, the nurse would check that it is the correct size. The wrong size condom sheath can cause complications. The nurse would then remove the condom sheath, cleanse the skin on the penis, and apply a skin barrier or protectant to improve adhesion. The nurse would also remind the client that the catheter is in place so that the client does not tug at the tubing. The catheter would not be discarded; rather, a new condom sheath may be applied. The penis should be dry and not lubricated. The health care provider does not need to be notified unless the situation is recurring.

Which assessment findings will the nurse use to determine the stage of a client's pressure injury? Select all that apply. -Full-thickness tissue loss -Visible subcutaneous fat -Drainage is foul smelling and green in color -No bone, tendon, or muscle visible. -Skin around injury is red and warm to touch

Full-thickness tissue loss , Visible subcutaneous fat , No bone, tendon, or muscle visible. Explanation: The assessment findings which will help the nurse determine the stage of a client's pressure injury are: subcutaneous fat is visible; there is full-thickness tissue loss; and no bone, tendon, or muscle is visible in the wound bed. This information should lead the nurse to document this as a stage 3 pressure injury. The skin being red and warm to the touch and the green foul drainage are indications of wound infection, but do not influence the staging of the client's pressure injury.

The nurse places a bedpan under the buttocks of a client and asks the client to roll back over on the bedpan. What would be another method of having the client assist with getting on a bedpan?

Have the client flex his or her knees and lift the buttocks onto the bedpan. Rationale: The nurse can have the client bend his or her knees, lift the buttocks off the bed, and place the bedpan under the raised buttocks. Wedging the bedpan down from the lower back area would cause skin irritation. If the client can sit up or stand they may not need to use a bedpan; a bedside commode may be a better choice.

A client reports a burning sensation when urinating for the first time following the removal of an indwelling urinary catheter. In this situation, what would be the nurse's intervention?

Inform the client that this is normal for the first few voids. Rationale: Following removal of a urinary catheter, the client may experience burning or irritation the first few times he or she voids, due to urethral irritation. This would not be the time to notify the health care provider of a possible urinary tract infection unless the symptoms continue. A nurse does not schedule urinalysis; this is the responsibility of the health care provider. If the catheter was in place for more than a few days, the nurse would monitor for urinary retention, but this would not cause a burning sensation.

When removing an indwelling urinary catheter from a client, the nurse prepares to deflate the catheter balloon. Which is the proper method for deflating the balloon?

Insert a syringe into the balloon inflation port and allow the water to come back by gravity. Rationale: The nurse, when deflating the balloon on an indwelling urinary catheter, would insert the syringe into the balloon inflation port and allow the water to come back by gravity. Alternatively, the nurse could insert the syringe into the balloon inflation port and aspirate all of the sterile water that was used to inflate the balloon. All of the water must be removed to prevent injury to the client. The tube would not be pulled out until the balloon is deflated, and air would not be instilled into the tube.

What is the most important advantage of using a condom catheter versus an indwelling catheter?

Less potential for infection. Rationale: The condom catheter is applied externally to the penis and is noninvasive, unlike an indwelling catheter. This reduces the potential for infection in the urinary tract. Nursing care of a client with a condom catheter includes vigilant skin care to prevent excoriation. This includes removing the condom catheter daily, washing the penis with soap and water, drying it carefully, and inspecting the skin for irritation. Promotion of client privacy is very important. A condom catheter is not a sterile set-up; therefore, a urinary catheter is used to obtain a sterile urine specimen.

What action would the nurse perform when removing a bedpan following client use?

Lower the head of the bed slightly. Rationale: The nurse would lower the head of the bed slightly and remove the bedpan in the same manner in which it was offered, being careful to hold it steady. Proper client positioning facilitates client assistance with the bedpan removal, conserving the nurse's energy.

What is the most important intervention the nurse can perform to prevent skin breakdown for clients using a bedpan?

Provide skin and perineal care after bedpan use. Rationale: When a client uses a bedpan, the nurse would provide skin care and perineal hygiene after bedpan use to prevent skin breakdown. Client teaching provides instruction for the proper use of a bedpan. A moisture-proof barrier on the buttocks is not a recommended guideline. The choice of a bedpan does not normally affect skin breakdown.

The client experiences leakage around the condom catheter. Which action does the nurse perform?

Obtain the correct supplies and replace it. Rationale: The nurse gathers supplies such as a correctly fitting condom catheter, cleanses the skin, applies skin barrier, and applies a new condom sheath with a leg strap. Indwelling catheters can lead to urinary tract infections and are only used if necessary. If the client could adequately use the urinal, the condom catheter would not have been placed. It is incorrect to place a brief on the client prior to ensuring that a condom catheter is correctly applied and used, because this catheter can reduce moisture, irritation, and complications.

The nurse is positioning a client for the removal of an indwelling urinary catheter. Where should the nurse stand during the procedure?

On the client's left side, if left handed. Rationale: The nurse would adjust the bed to a comfortable working position and stand at the client's left side, if left handed and at the right side, if right handed. Proper positioning allows access to the site and ensures proper body mechanics for the nurse performing the procedure.

The nurse has placed a urinal between the legs of a client and instructed him to place himself onto the urinal. After covering the client with the bed linens, what would be the nurse's next action?

Place the call bell and toilet paper next to the client and instruct him to call when he is finished. Rationale: After covering the client with the bed linens, the nurse would place the call device and toilet tissue within easy reach and have a receptacle, such as a plastic trash bag, for discarding tissue. The nurse would also ensure the bed is in the lowest position and leave the client if it is safe to do so. Leaving the client alone, if possible, promotes self-esteem and shows respect for privacy.

The nurse has assisted the bedbound client to place the urinal between the legs. The nurse instructs the client to place the penis into the urinal. After covering the client with the bed linens, what would be the nurse's next action?

Place the call bell and toilet paper next to the client and instruct the client to call when finished urinating. Rationale: After covering the client with the bed linens, the nurse would place within easy reach the call device, toilet tissue, and a receptacle for discarding tissue, such as a plastic trash bag. The nurse would also ensure the bed is in the lowest position and leave the client if it is safe to do so. Leaving the client alone, if possible, promotes self-esteem and shows respect for privacy.

Prior to placing the bedpan under a client's buttocks, what would the nurse apply to the bedpan if a urine specimen is not needed?

Powder Rationale: The nurse would dust the bedpan with powder to keep it from sticking to the client's skin and for easier removal. However, this action would not be performed if a urine specimen were needed. Alcohol, petroleum jelly, and lubricant are not used on the surface of the bedpan.

The nurse is disposing the contents of the client's urinal. What is the correct procedure for cleaning the urinal?

Put on clean gloves, rinse the urinal with water, and dry with paper towel. Rationale: The nurse would put on clean gloves, pour the contents of the urinal into the toilet, rinse the urinal with water, and dry the urinal with paper towels before returning it to the client. Putting on clean gloves prevents exposure to blood and body fluids. The urinal does not need to be disinfected with alcohol or antimicrobial cleanser or sent out for disinfection.

When removing an indwelling urinary catheter from a client, the nurse notices resistance while attempting to pull out the catheter. What would be the immediate intervention in this situation?

Reattach the syringe to the port, aspirate again, and reattempt catheter removal. Rationale: If resistance is met while attempting to pull out an indwelling catheter, the nurse would stop pulling the catheter, reattach the syringe to the balloon inflation port, and aspirate again to make sure all the sterile water has been removed. The nurse would then reattempt the catheter removal. If resistance is still felt, the nurse would notify the health care provider. The nurse would not irrigate the aspiration port with 20 mL sterile saline, and air should not be used to reinflate the balloon.

The nurse is inserting an indwelling urinary catheter for an uncircumcised male client. After the catheter has been anchored properly, what is an important step for the nurse?

Replace the foreskin into its non-retracted position. Rationale: The foreskin will need to be replaced into its natural position. Leaving it retracted could increase swelling and stricture, making it painful for the client. Therefore, the foreskin should not stay retracted. Monitoring for signs of infection in a catheterized client is important, but the foreskin would not show immediate signs of infection right after catheterization. The foreskin should not need to be vigorously cleansed as cleaning has already occurred.

In what position would the nurse place a female client who is using a bedpan?

Sitting upright. Rationale: The nurse would raise the client to a sitting position to provide comfort and to facilitate the emptying of the bladder.

The nurse observes a reddened area with intact skin over the client's coccyx. When gentle pressure is applied, the area does not blanch. How will the nurse document this finding? -Stage 2 pressure injury -Stage 1 pressure injury -Deep tissue injury -Unstageable, skin intact

Stage 1 pressure injury. Explanation: This finding should be documented as a stage 1 pressure injury. The description of stage 1 pressure injury includes intact skin with nonblanchable redness. In a stage 2 pressure injury, the skin would not be intact, and there is partial-thickness skin loss involving epidermis, dermis, or both. Deep tissue injuries are characterized by a purple or maroon localized area of discolored intact skin or blood-filled blister caused by damage to underlying soft tissue from pressure and/or shear. An unstageable pressure injury has slough, which is a yellowish stringy substance attached to the wound bed, or eschar, which is black or brown necrotic tissue covering the wound, which prevents knowledge of the depth of the wound.

A nurse is performing a catheterization of a male client. The nurse meets resistance when advancing the catheter. What should the nurse try before stopping the procedure and notifying the health care provider?

Stop for a moment and have the client take several slow, deep breaths. Rationale: By stopping for a moment and having the client take several slow, deep breaths the urethra may relax, making advancing easier. Twisting the catheter vigorously or increasing the force of the catheter could cause damage to the urethra or prostate. The catheter should not be removed and reused, because this increases the risk of contamination.

The nurse is caring for a client with a pressure injury on the heel of the foot. The injury is covered with stable black eschar. What is the best nursing intervention at this time? -Prescribe the client a high carbohydrate diet to promote healing. -Remove the eschar by irrigating with sterile saline. -Teach the client to reposition every 4 hours. -Teach the client ways to relieve the pressure on the heel.

Teach the client ways to relieve the pressure on the heel. Explanation: The best nursing intervention at this time is to teach the client ways to relieve the pressure on the heel to prevent further damage. Stable eschar serves as "the body's natural (biological) cover" and is only removed by health care provider order. Teaching the client to reposition is a good intervention, but the client should be taught to reposition at least every 2 hours. The client would need adequate protein to promote healing, not carbohydrate.

A nurse is assisting a client with the use of a bedpan. The nurse understands that which statement about bedpans is true?

The largest part of a regular bedpan should be placed under the client's buttocks. Rationale: The rounded, smooth upper end of the regular bedpan is designed to be placed under the buttocks. Because a regular bedpan is much larger than a fracture bedpan, it is usually less comfortable. Choice of bedpan is based on client characteristics rather than type of elimination. A fracture bedpan can be used for any client.

The nurse is assisting a client who is immobilized with a neck injury to use a bedpan for urinary elimination. What is one of the primary nursing goals when assisting a client with urinary elimination?

To promote comfort and normalcy with urinary elimination. Rationale: Many clients find it difficult and embarrassing to use a bedpan. When helping a client use a bedpan, the nurse would promote comfort and normalcy, and respect the client's privacy as much as possible. A client's normal voiding habits should be encouraged. The nurse would also provide interventions to avoid incontinence in clients.

The nurse is caring for a client with a pressure injury and is applying a saline-moistened dressing to the wound. What does the nurse understand to be the primary rationale for using a saline-moistened dressing? -To prevent the dressing from sticking to the wound. -To fill the wound with saline to dissolve wound secretions. -To promote moist wound healing and protect the wound from contamination and trauma. -To soften the dressing to prevent trauma to the wound bed.

To promote moist wound healing and protect the wound from contamination and trauma. Explanation: Saline-moistened dressings are used to maintain a moist wound environment to promote moist wound healing and protect the wound from contamination and trauma. A moist wound surface enhances the cellular migration necessary for tissue repair and healing. It is important that the dressing material be moist, not wet, when placed in open wounds. Although a moist dressing may also prevent sticking to the wound, this is not its primary purpose.

The nurse is teaching a client's caregiver about ways to help prevent skin breakdown. What would the nurse teach as an important intervention to prevent pressure injury development? -Pull the client up in the bed very gently. -Gently massage any reddened areas for several minutes. -Keep the head of the bed elevated 35 degrees. -Turn and reposition the client every 2 hours.

Turn and reposition the client every 2 hours. Explanation: Pressure injuries are a result of unrelieved pressure that damages underlying tissues. Teaching the caregiver to turn and reposition the client every 2 hours is an important intervention to help prevent unrelieved pressure from causing pressure injury to tissues. Keeping the head of the bed elevated will help to prevent aspiration but does not prevent pressure injury. The caregiver should be taught how to use a draw sheet to lift the client and then move the client up in bed. The client should not be pulled, because this causes a shearing force which can easily injure tissue. Reddened areas should not be massage so this should not be taught to the caregiver.

The client has had surgery to repair a left hip fracture. The client is asking to use the bedpan. How should the nurse assist the client onto the bedpan? Select all that apply.

Turn the client onto the unaffected leg to place the bedpan. , Seek assistance from another nurse to support the affected leg. , Ensure the client's buttocks are resting on the shallow rim of bedpan. Rationale: Because the client has had hip repair surgery the hip should only be moved in the amount of flexion, extension, and rotation prescribed by the health care provider. The nurse will be unable to support the leg in the correct position and place the bedpan. The assistance of another nurse will be needed. The client should be rolled onto the unaffected leg to avoid surgical incisions and provide less pain from the movement. The head of the bed should be elevated only to 30 degrees to provide proper body alignment. The client's buttocks should be positioned on the upper end of the bedpan prior to rolling over onto the bedpan. This will allow for the final position of the client's buttocks to be resting on the shallow rim of the bedpan after turning.

The nurse is helping to clean a female client who has urinated into a bedpan. What is the recommended guideline for this action?

Use toilet paper to wipe the client from the pubic area to the anal area. Rationale: When the client needs assistance with hygiene, the nurse would wrap tissue around his or her hand several times, and wipe the client clean, using one stroke from the pubic area toward the anal area. The nurse would discard the tissue and use more until the client is clean. Cleaning the client from the front to the back minimizes fecal contamination of the vagina and urinary meatus. Cleaning the client after bedpan use minimizes offensive odors and irritation of the skin.

The nurse is inserting an indwelling urinary catheter for a male client. How should the nurse properly cleanse the area prior to catheter insertion?

Using a circular motion, move from the meatus down the glans of the penis. Rationale: Moving from the meatus down the glans toward the base of the penis prevents bringing microorganisms to the meatus. Other methods increase chances of bringing contamination of microorganisms toward the meatus.

The nurse is caring for a male client with an indwelling urinary catheter. Where does the nurse correctly place the bag of the catheter?

attached to the bed itself lower than the client Rationale: The catheter bag should be attached to the bed itself and positioned lower than the client. If it is attached to the side rail, it could become pulled or dislodged. The bag should not be placed in bed with the client or on the floor.

The nurse has documented that a client has an unstageable pressure injury. Which statement best describes this type of wound? The wound:

has black brown eschar covering the top. Explanation: Wounds that have slough (yellow, tan, gray, green, or brown stringy tissue) or eschar covering them are considered unstageable as it is not possible to determine their depth until the slough or eschar is removed. A wound that has exposed bone, tendon, or muscle visible would be considered stage 4. A wound that has redness with partial thickness loss of dermis would be considered stage 2, and a wound with bright red granulation tissue in the wound bed would be considered healing, although there is not enough information to stage this wound.

The nurse is inserting an indwelling urinary catheter for an uncircumcised male client. Prior to filling the catheter balloon, how far should the nurse insert the catheter?

to the catheter bifurcation Rationale: The male urethra is about 20 cm long. By inserting the catheter all the way to the catheter bifurcation, this minimizes the risk of inadvertently inflating the balloon while it is still in the urethra.