Review

A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of the following indications should the nurse include?

-Relief of urinary retention -Measurement of residual urine after urination -Presence of an open perineal wound

A nurse in a long-term care facility is observing an assistant personnel (AP) changing the linen for a client who has fecal incontinence. Which of the following actions indicates that the AP understands the principles of infection control?

Places clean linen that touched the floor in the soiled linen bag. --- Linen that touches the floor or the AP drops requires laundering.

A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take?

Suction two to three times with a 60-second pause between passes. --- Copious secretions may require several passes of the suction catheter. An interval of 60 seconds should be allowed between passes to prevent hypoxia.

A nurse is caring for a patient who has the following arterial blood gas results : HCO3 18mEq, PaCO2 28mm Hg, and pH 7.30. The nurse recognizes the client is experiencing which of the following acid base imbalances?

metabolic acidosis --- Metabolic acidosis MY ANSWER A client experiencing metabolic acidosis would have a decreased pH, a decreased HCO3 and a decreased PaCO2.

A nurse is assessing a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection?

-An increase in neutrophils -Localized edema --- -An increase in neutrophils is correct. During the inflammatory stage of wound healing, neutrophils move into the interstitial spaces. About 24 hr later, macrophages replace them and ingest and destroy micro-organisms. -Localized edema is correct. Edema develops in the first stage of inflammation, when vascular and cellular responses cause fluid, WBCs, and protein to pour into the interstitial spaces at the site of the invasion of micro-organisms. The accumulated fluid appears as localized swelling or edema.

A nurse is adhering to standard precautions while caring for a group of clients. For which of the following tasks should the nurse wear protective eye equipment?

-Irrigating a client's abdominal wound -Suctioning a client's new tracheostomy tube --- -Irrigating a client's abdominal wound is correct. The nurse should wear protective eyewear when irrigating a wound because wound exudate and fluids could splash into her eyes. -Suctioning a client's new tracheostomy tube is correct. The nurse should wear protective eyewear when performing tracheal suctioning because the client's secretions could splash into her eyes.

A nurse is preparing a sterile field prior to inserting a urinary catheter for a client. Identify the sequence of steps the nurse should plan to follow.

-Perform hand hygiene -Place package on work surface -Open outermost flap away from self -Open side flap, pulling to the side -Open innermost flap toward self -Use inner surface of package as sterile field

A nurse is caring for a client who has an NG tube. The nurse tests the pH of the secretions to determine if the tube is correctly placed. Which of the following readings should the nurse expect?

4.0 --- This is an acidic pH, which is consistent with gastric drainage. This indicates that the NG tube is correctly placed.

A charge nurse is reviewing guidelines for initiating airborne precautions. Which of the following clients should the nurse identify as requiring airborne precautions?

A client who has measles. --- A client who has measles requires airborne precautions as well as a negative pressure room.

A nurse on a medical unit is assessing four clients for urinary retention. Which of the following clients have manifestations of urinary retention?

A client who reports urinary frequency. --- Voiding a small amount of urine (less than 100 mL) frequently (2 to 3 times per hr), and dribbling of urine are manifestations of urinary retention.

A nurse working on an orthopedic unit is caring for four clients. Which of the following clients should the nurse identify as being at greatest risk for skin breakdown?

An older adult who has a hip fracture and is in Buck's traction. --- According to evidenced-based practice, this client has multiple risk factors for skin breakdown: the aging process (decreased muscle mass, thin and fragile skin) and the limitation of movement due to traction. Therefore, this client is at the greatest risk for skin breakdown.

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown?

Apply moisture barrier ointment to the client's skin. --- Skin that remains in contact with urine for prolonged periods is at risk for maceration and breakdown. After cleansing and drying the client's skin, the nurse should apply a moisture barrier ointment to prevent further contact of the skin with urine.

A nurse is preparing to administer a soapsuds enema to an adult client. Which of the following actions should the nurse take?

Assist the client to the left Sims' position. --- This position makes it easier for the enema solution to flow by gravity into the sigmoid and descending colon. The nurse should also have the client's right leg flexed to facilitate insertion.

A nurse is assessing a client who is 2 days postoperative and auscultates bilateral breath sounds, but absent breath sounds in the bases. The nurse should suspect which of the following postoperative complications?

Atelectasis --- is an incomplete alveolar expansion or collapse. Breath sounds are dull or absent over areas of alveolar collapse.

A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions?

Atelectasis --- Atelectasis is the collapse of part or all of a lung by blockage of the air passages (bronchus or bronchioles) or by hypoventilation. Prolonged bedrest with few changes in position, ineffective coughing, and underlying lung disease are risk factors for the development of atelectasis.

A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions?

Encourage the client to increase fluid intake. --- Increasing fluid intake to1,500 to 2,500 mL/day promotes liquefaction and thinning of pulmonary secretions, which improves the client's ability to cough and remove the secretions.

A nurse is caring for a client who has metabolic alkalosis. For which of the following clinical manifestations should the nurse monitor?

Bicarbonate excess, Circumoral parethesia --- -Bicarbonate excess is correct. Bicarbonate excess is a clinical manifestation for a client experiencing metabolic alkalosis. -Circumoral paresthesia is correct. Circumoral paresthesia is a clinical manifestation for a client experiencing metabolic alkalosis.

A nurse is caring for a client who is postoperative and has a prescription for antiembolic stockings. Which of the following actions should the nurse take?

Check the stockings for wrinkles. --- The nurse should check the stockings for wrinkles or constriction that can increase the risk for skin breakdown or reduced circulation.

A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer?

Necrotic subcutaneous tissue. --- Manifestations of a stage 3 pressure ulcer can include full-thickness skin loss with necrotic subcutaneous tissue.

A nurse is reviewing a client's laboratory report of blood gas findings: HCO3- 18 mEq/L and PaCO2 28 mm Hg. Which of the following pH values and conditions should the nurse expect when interpreting these findings?

Decreased pH and metabolic Acidosis --- This client would have a decreased pH and be in metabolic acidosis. Other findings would include diarrhea, circulatory shock, decreased level of consciousness, abdominal pain, cardiac dysrhythmia, and increased depth and rate of respirations.

A nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toe nails. The nurse should apply the pulse oximeter probe to which of the following locations?

Earlobe --- The earlobe is rarely edematous, is the least affected by decreased blood flow, and has greater accuracy when measuring oxygen saturation.

A nurse is removing personal protective equipment (PPE) after giving direct care to a client who requires isolation. Which of the following PPE items should the nurse remove first?

Gloves --- According to evidence-based practice, the nurse should remove the most contaminated item, the gloves, first.

A nurse is caring for a client who has active pulmonary tuberculosis (TB). The client requires airborne precautions and is receiving multi-drug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiology department for a chest x-ray?

Have the client wear a mask. --- When a client who has a communicable disease must leave his room, it is important to protect everyone with whom the client comes in contact. Having the client wear a mask protects others from airborne particles should the client cough.

A nurse is teaching an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching?

Increase dietary intake of raw vegetables. --- The client should increase dietary intake of raw vegetables to help provide fiber in the diet, which will increase stool bulk and move the stool through the colon to prevent constipation.

A nurse working in an emergency room is assessing a client who has a leg wound. The nurse notes a full thickness wound with jagged edges and muscle tissue visible. The nurse should documents this as which of the following types of wounds?

Laceration --- Lacerations are open wounds of varying depths caused by a tearing of soft body tissues. The edges are often jagged and irregular. Lacerations are often considered contaminated wounds because of the introduction of bacteria or debris that can be in the wound.

A nurse is caring for a client who requires droplet precautions. Which of the following personal protective equipment should the nurse wear when setting the client's meal tray?

Mask --- The nurse should follow droplet precautions for clients who have infections that spread by droplets larger than 5 microns. The nurse should wear a mask whenever she is within 1 m (3 ft) of the client.

A nurse is caring for a client who has a Clostridium difficile infection. Which of the following cleansing agents should the nurse use for hand hygiene?

Nonantimicrobial soap --- The Centers for Disease Control recommends that hands should be washed with nonantimicrobial soap and water if in contact with spore-forming organisms such as Clostridium difficile or Bacillus anthracis. Proper hand hygiene includes using soapy lather and friction under running water for at least 15 seconds.

A nurse is caring for client who has an infection. The nurse should use which of the following strategies to prevent the transmission of the client's infection?

Performing hand hygiene before, during and after direct contact with the client. --- The nurse can help prevent the transmission of micro-organisms by washing her hands frequently before, during, and after client care procedures.

A nurse is teaching a newly hired group of assistive personnel (AP) about infection-control measures on the unit. It is crucial for the nurse to remind the APs that which of the following is the most effective way to prevent the spread of pathogens during client care?

Performing hand hygiene frequently and consistently. --- The greatest risk to all clients and staff on the unit is infection from cross contamination; therefore, the priority action is hand hygiene. It is one of the most important and effective ways to prevent pathogen transmission. It applies to every health care setting and is a consistent imperative during client care.

A nurse is caring for a client who has returned to the unit following a surgical procedure. The client's oxygen saturation in 85%. Which of the following actions should the nurse take first?

Raise the head of the bed --- Elevating the head of the bed uses gravity to reduce pressure on the diaphragm from the abdominal organs and allows for increased expansion of the lungs. The head and neck can be extended, which promotes a patent airway. This is the first action the nurse should take and is the least invasive.

A nurse is preparing a sterile field. Which of the following actions should the nurse perform when opening the sterile pack?

Reach around the pack and open the top flap away from the body. --- The nurse should pull the uppermost flap away from her body, grasping it from the side to avoid reaching over the sterile field and contaminating it.

A nurse is auscultating a client's lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take?

Repeat auscultation after asking the client to breathe deeply and cough. --- Although crackles often indicate fluid in the alveoli, they can also be the result of positioning or decreased ventilation. They sometimes clear after a deep breath or a cough.

A nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan?

Reposition the client at least every 2 hr. --- The nurse should plan to reposition the client at least every 2 hr and to make a schedule to record position changes for the client's medical record.

A nurse is preparing to discharge a client who has an abdominal wound that is healing by secondary intention. Which of the following actions is the nurse's priority?

Schedule a follow-up visit by a home health nurse, for dressing changes. --- The greatest risk to this client is injury from a wound infection. Therefore, the priority action the nurse should take is to schedule a follow-up visit by a home health nurse for dressing changes. Wounds healing by secondary intention are open and have edges that are not approximated, which increases the risk for infection.

A nurse is administering a cleansing enema to a client who reports mild cramping. The client asks the nurse to stop the enema and allow him to go to the bathroom. Which of the following actions should the nurse take?

Slow the flow of enema solution briefly. --- Slowing the enema solution flow temporarily prevents cramping.

A nurse is assessing a client who has hypoxia. Which of the following findings should the nurse expect?

Tachycardia --- The nurse should expect the client who has hypoxia to manifest tachycardia.

A nurse is reviewing the medical record for a client who has a health care-associated infection (HAI). The nurse should identify which of the following findings as a risk factor for acquiring an HAI?

The client is 71 years old. --- Clients older than 70 years of age are at an increased risk of acquiring an HAI. Decreased immune system function increases the susceptibility to infection.

A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

Use a transfer device to lift the client up in bed. --- Using a lifting device prevents dragging the client's skin across the bed linens, which can cause abrasions.

A nurse is planning to perform a sterile dressing change for a client. Which of the following actions should the nurse plan to take?

Use sterile forceps to move the sterile items on the sterile field. --- A sterile object remains sterile only if the nurse touches it with another sterile object. This principle guides the nurse in placement of sterile objects and how she should handle them such as using sterile forceps or wearing sterile gloves to handle objects on a sterile field.

A nurse is planning care for a client who requires airborne precautions/ Which of the following actions should the nurse take?

Wear an N95 respirator mask --- he nurse should wear an N95 respirator mask or a high-efficiency particulate air (HEPA) filter mask when caring for a client who has an infection that requires airborne precautions, such as disseminated varicella zoster, rubeola, or tuberculosis.