4335 Midterm

When caring for a client after a thoracotomy, which action would the nurse take to keep the chest tube and closed chest drainage system patent? 1. Position the drainage system below the level of the client's heart. 2. Empty the collection chamber and measure contents every 12 hours. 3. Assure that a daily chest x-ray is done to check chest tube position. 4. Keep the client on bed rest until the chest tube is discontinued.

1. Position the drainage system below the level of the client's heart.

The nurse uses the same pair of gloves to remove a soiled dressing and to apply a new sterile dressing. Another nurse is observing the dressing change procedure. Which initial action would the observing nurse take? 1. File an incident report. 2. Discuss the incident with the nurse. 3. Offer to demonstrate the proper technique. 4. Report the individual to the nursing supervisor.

2. Discuss the incident with the nurse

Which clinical manifestation would the nurse expect when assessing a client with atelectasis? 1. Hyperresonance to percussion 2. Rhonchi and wheezes 3. Sudden onset shortness of breath 4. Crackles at the bases

4. Crackles at the bases

Which nursing assessment supports a diagnosis of atelectasis in a postoperative client? 1. Productive cough 2. Clubbing of the fingertips 3. Low-pitched expiratory rhonchi 4. Diminished breath sounds on auscultation

4. Diminished breath sounds on auscultation

Which action will the nurse take when a client's chest x-ray shows atelectasis? 1. Administer oxygen. 2. Suction the upper airway. 3. Position for postural drainage. 4. Encourage incentive spirometer use.

4. Encourage incentive spirometer use.

Which action will the nurse take to support safe oral intake after tracheostomy? 1. Include thin liquids. 2. Provide large meals. 3. Inflate the tracheostomy cuff fully. 4. Position client as upright as possible.

4. Position client as upright as possible.

Which finding in a client who has home oxygen therapy with a tracheostomy collar requires immediate action by the home health nurse? 1. Condensation in the tubing 2. Oxygen flow rate 9 L/min 3. Low fluid level in the humidifier 4. Scented candle burning in the room

4. Scented candle burning in the room

In which order would the nurse complete these steps when administering a blood transfusion?

1. Check primary health care provider's prescription. 2. Obtain vital signs and history of transfusions. 3. Ascertain that intravenous catheter size is 18 or 20 gauge. 4. Change main line solution to normal saline. 5. Check client identification before hanging unit of blood.

A health care provider prescribes two units of blood for a client. Which nursing interventions are necessary before the blood transfusion is administered? Select all that apply. One, some, or all responses may be correct. 1. Obtain the client's vital signs. 2. Monitor hemoglobin and hematocrit levels. 3. Allow the blood to reach room temperature. 4. Determine typing and crossmatching of blood. 5. Use a Y-type infusion set to initiate 0.9% normal saline.

1. Obtain the client's vital signs 4. Determine typing and crossmatching of blood. 5. Use a Y-type infusion set to initiate 0.9% normal saline.

A client develops subcutaneous emphysema after the surgical creation of a tracheostomy. Which assessment by the nurse most readily detects this complication? 1. Palpating the neck or face 2. Evaluating the blood gases 3. Auscultating the lung fields 4. Reviewing the chest x-ray film

1. Palpating the neck or face

Which would the nurse do first if an allergic reaction to a blood transfusion occurs? 1. Shut off the infusion. 2. Slow the rate of flow. 3. Administer an antihistamine. 4. Call the health care provider (HCP).

1. Shut off the infusion.

When the nurse is assessing a client after tracheostomy placement, which finding requires immediate action by the nurse? 1. Crackling of the skin on palpation 2. Small amount of blood at the surgical site 3. Client reports the area around incision is tender 4. The client is unable to speak with a cuffed tube

1. Crackling of the skin on palpation

A home health nurse teaches a family member to cleanse a client's wound and apply a sterile dressing. Which action by the family member during a return demonstration indicates the need for additional teaching? 1. Placing the old dressing in a plastic bag 2. Changing the dressing without wearing a mask 3. Donning nonsterile gloves for removing the old dressing 4. Using a back-and-forth motion with the same gauze while cleaning the wound

4. Using a back-and-forth motion with the same gauze while cleaning the wound

Which actions will the nurse include in the plan of care for a client with a left pneumothorax who has a chest tube in place? Select all that apply. One, some, or all responses may be correct. 1. Immobilize the left arm in a sling. 2. Check the water-seal chamber for air bubbling. 3. Avoid use of nonsteroidal anti-inflammatory drugs. 4. Keep the client on bed rest in semi-Fowler position. 5. Observe frequently for drainage in the collection chamber. 6. Assist the client to cough and deep breathe every hour while awake.

2. Check the water-seal chamber for air bubbling. 6. Assist the client to cough and deep breathe every hour while awake.

When a client who has a chest tube after thoracotomy reports sharp chest pain at the chest tube and refuses to take deep breaths, which action by the nurse is best? 1. Assist the client to sit up in a chair. 2. Administer prescribed pain medications. 3. Educate about the reason for deep breathing. 4. Explain that some pain is normal with a chest tube.

2. Administer prescribed pain medications

The nurse is suctioning a client's airway. Which nursing action will limit hypoxia? 1. Limit suctioning with catheter to 30 seconds. 2. Apply suction only after the catheter is inserted. 3. Lubricate the catheter with saline before insertion. 4. Use a sterile suction catheter for each suctioning episode.

2. Apply suction only after the catheter is inserted.

A client who had a cesarean birth is unable to void 3 hours after the removal of an indwelling catheter. How would the nurse evaluate the client for bladder distension? 1. By catheterizing the client for residual urine 2. By palpating the client's suprapubic area gently 3. By asking the client whether she still feels the urge to urinate 4. By determining whether the client is experiencing suprapubic pain

2. By palpating the client's suprapubic area gently

After thoracic surgery, a client has a chest tube connected to a water-seal drainage system that is attached to suction. When excessive bubbling is observed in the water-seal chamber, which action would the nurse take? 1. Strip the chest tube catheter. 2. Check the system for air leaks. 3. Decrease the amount of suction pressure. 4. Recognize that the system is functioning correctly

2. Check the system for air leaks.

When a client's total parenteral nutrition (TPN) bag is empty, which action is appropriate for the nurse to take? 1. Perform a finger stick glucose test and call the primary health care provider with the results. 2. Hang a bag of 10% dextrose at the ordered TPN rate and place an urgent request for the next TPN bag. 3. Discontinue the infusion and flush the intravenous (IV) line with saline solution until the next TPN bag is ready.

2. Hang a bag of 10% dextrose at the ordered TPN rate and place an urgent request for the next TPN bag.

Which dressing technique promotes autolysis in the spontaneous separation of necrotic tissue? 1. Continuous wet gauze 2. Moisture-retentive covering 3. Topical enzyme preparations 4. Wet-to-dry damp saline moistened gauze

2. Moisture-retentive covering

Which action needs correction regarding insertion of an intravenous cannula for administration of fluids? 1. Washing hands with antibacterial soap before insertion of cannula 2. Using chlorhexidine at the selected site of insertion 3. Shaving the client's skin immediately around the insertion site 4. Applying skin protectant solutions at the site of insertion

3. Shaving the client's skin immediately around the insertion site

The intravenous (IV) line infiltrates and needs restarting on a client diagnosed with acquired immunodeficiency syndrome (AIDS). Which precautions would the nurse take when restarting the IV? Select all that apply. One, some, or all responses may be correct. 1. Mask 2. Gown 3. Gloves 4. Face shield 5. Hand hygiene

3. Gloves 5. Hand hygiene

A client who has just had a cesarean birth is receiving intravenous fluids and has an indwelling catheter. Which finding would indicate a need for an increase in the client's fluid intake? 1. Dark-amber urine 2. Urinary suppression 3. Tinges of blood in the urine 4. Cloudiness of the urine

1. Dark-amber urine

A client is scheduled to receive total parenteral nutrition (TPN). To administer TPN, which piece of equipment is important for the nurse to obtain? 1. Infusion pump 2. Tall intravenous (IV) pole 3. Clamp that will be taped at the bedside 4. Infusion set that delivers 60 drops/mL

1. Infusion pump

Arrange the order of pathophysiology involved with the development of pressure ulcers on the sacrum, hips, and ankles of a client with quadriplegia.

1. Local tissue compression 2. Restriction of blood flow 3. Reduced tissue perfusion 4. Local cell death 5. Development of pressure ulcers

In which order would the nurse treat the infiltration of a nonvesicant intravenous (IV) solution leaking into the extravascular tissue?

1.Stop infusion and remove peripheral venous catheter. 2.Apply a sterile dressing. 3. Elevate the extremity. 4. Use warm or cold compresses according to the solution infiltrated 5. Insert a new catheter in the opposite extremity 6. Obtain a study to determine the cause of the problem. 7. Rate the infiltration using the INS Infiltration Scale and document the procedure.

A client who had a transurethral resection of the prostate (TURP) experiences dribbling after removal of the indwelling catheter. Which response to the client would the nurse use? 1. "I know you're worried, but the dribbling will go away in a few days." 2. "Increase your fluid intake and urinate at regular intervals." 3. "Limit your fluid intake and urinate when you first feel the urge." 4. "The catheter will have to be reinserted until your bladder regains its tone."

2. "Increase your fluid intake and urinate at regular intervals."

The registered nurse is teaching a student nurse about the use of a suction pump in negative-pressure wound therapy. Which statement by the student nurse indicates the need for further teaching? 1. "The wound site should be monitored at least every 2 hours." 2. "This treatment is used mostly for areas of skin cancer." 3. "The foam dressing should be changed every 48 to 72 hours." 4. "A continuous low-negative pressure should be maintained."

2. "This treatment is used mostly for areas of skin cancer."

The client's intravenous (IV) site is tender with erythema, warmth, and mild edema. Which action will the nurse take? 1. Irrigate the IV tubing. 2. Change the IV site. 3. Slow the rate of the infusion. 4. Obtain a prescription for an analgesic.

2. Change the IV site.

When providing care for a client with quadriplegia, which nursing intervention assists in decreasing the potential occurrence of pressure ulcers? 1. Avoid massaging the client's legs. 2. Frequently reposition the client on a scheduled basis. 3. Increase the fiber content in the client's food. 4. Encourage the client to participate in weight-bearing exercises.

2. Frequently reposition the client on a scheduled basis.

During a blood transfusion a client develops chills and a headache. Which intervention is the priority nursing action? 1. Cover the client. 2. Stop the transfusion. 3. Take the client's vital signs. 4. Notify the health care provider.

2. Stop the transfusion.

Which findings are expected when assessing the skin of an older adult? Select all that apply. One, some, or all responses may be correct. 1. Scaly skin 2. Tenting of skin 3. Transparent skin 4. Increased wrinkles 5. Pigmented lesions

2. Tenting of skin 3. Transparent skin 4. Increased wrinkles 5. Pigmented lesions

A client is to receive a transfusion of packed red blood cells (PRBCs). Which solution would the nurse use to prime the blood intravenous (IV) tubing? 1. Lactated Ringer solution 2. 5% dextrose and water 3. 0.9% normal saline 4. 0.45% normal saline

3. 0.9% normal saline

After a transurethral vaporization of the prostate, the client returns to the unit with an indwelling urinary catheter and a continuous bladder irrigation. The client reports the need to urinate. What would the nurse do first? 1. Encourage the client to drink fluids. 2. Review the client's intake and output. 3. Assess that the tubing attached to the collection bag is patent. 4. Explain that the balloon inflated in the bladder causes this feeling.

3. Assess that the tubing attached to the collection bag is patent

Which condition would the nurse question using a negative-pressure wound treatment device? 1. Chronic ulcer 2. Upper thigh wound 3. Hip wound with slight bleeding 4. Treated osteomyelitis within the vicinity of the wound

3. Hip wound with slight bleeding

A client with a chest tube is to be transported via a stretcher. When transporting the client, what would the nurse do? 1. Keep collection device attached to mechanical suction 2.Keep chest tube clamped distal to the water-seal chamber 3. Keep collection device below the level of the client's chest 4. Keep chest tube end covered with sterile gauze pads taped to the client

3. Keep collection device below the level of the client's chest

The nurse is providing postoperative care to a client with cancer of the lung who had a lobectomy. The client has a chest tube attached to suction. Which assessment finding indicates a complication? 1. Clots in the tubing during the first postoperative day 2. Bloody fluid in the drainage-collection chamber on the first postoperative day 3. Subcutaneous emphysema on the second postoperative day 4. Decreased bubbling in the water-seal chamber on the third postoperative day

3. Subcutaneous emphysema on the second postoperative day

When teaching an older adult client about skincare to prevent pressure ulcers, which client statement indicates a misunderstanding? 1. "I should gently pat my skin." 2. "I should use mild, heavily fatted soap." 3. "I should wash my skin with tepid, rather than hot water." 4. "I should apply powders or talc on a perineum wound."

4. "I should apply powders or talc on a perineum wound."

Which nursing action would be included in the plan of care to promote the nutritional status of a client during the acute phase of treatment after extensive burns? 1. Provide a diet high in sodium. 2. Limit caloric intake to decrease the work of the body. 3. Reduce protein intake to avoid overtaxing the kidneys. 4. Administer the prescribed intravenous fluid with the added vitamin C

4. Administer the prescribed intravenous fluid with the added vitamin C

While walking in a hallway, a client with a chest tube becomes confused and pulls the chest tube out. Which action would the nurse take? 1. Place the client in the supine position. 2. Spread a clamp in the insertion site to hold the site open. 3. Obtain a sterile Vaseline gauze to cover the opening. 4. Cover the opening with the cleanest material available.

4. Cover the opening with the cleanest material available.

Which action would the nurse take to prevent complications when caring for a client with a chest tube to water seal drainage system for a pneumothorax? Select all that apply. One, some, or all responses may be correct. 1. Emptying the drainage system when full 2. Keeping the drainage system at heart level 3. Notifying the health care provider of drainage greater than 50 mL/h 4. Marking the time on the drainage unit every shift 5. Laying the drainage system on its side during transport

4. Marking the time on the drainage unit every shift

Which technology would the nurse use to reduce chronic ulcers by removing fluids from the wound? 1. Electrical stimulation 2. Topical growth factors 3. Hyperbaric oxygen therapy 4. Negative pressure wound therapy

4. Negative pressure wound therapy

When a norepinephrine intravenous infusion is prescribed for a client in septic shock, which intravenous line would the nurse choose for the infusion? 1. Implanted port 2. Midline catheter 3. 18-gauge peripheral venous catheter 4. Peripherally inserted central catheter (PICC) line

4. Peripherally inserted central catheter (PICC) line

Which instruction would the nurse provide a client needing to collect a clean-catch urine specimen? 1. "Urinate a small amount, stop flow, and then fill one half of the specimen cup." 2. "Collect a sample of the last urine voided during the night." 3. "If anticipating a delay in delivery, keep the urine sample in a warm, dry area." 4. "Send the urine sample to the laboratory within 6 hours of collection."

1. "Urinate a small amount, stop flow, and then fill one half of the specimen cup.

Which actions will the nurse take when caring for a client with a chest tube in place after thoracotomy? Select all that apply. One, some, or all responses may be correct. 1. Administer prescribed analgesic medications. 2. Check around chest tube insertion site for crepitus. 3. Clamp the chest tube before the client ambulates. 4. Add fluid to the suction control chamber as needed. 5. Milk the tubing toward the collection chamber. 6. Check for air bubbling in the water-seal chamber.

1. Administer prescribed analgesic medications 2. Check around chest tube insertion site for crepitus. 4. Add fluid to the suction control chamber as needed. 6. Check for air bubbling in the water-seal chamber.

A client develops acute respiratory distress, and a tracheostomy is performed. Which intervention is most important for the nurse to implement when caring for this client? 1. Encouraging a fluid intake of 3 L daily 2. Suctioning via the tracheostomy every hour 3. Applying an occlusive dressing over the surgical site 4. Using cotton balls to cleanse the stoma with peroxide

1. Encouraging a fluid intake of 3 L daily

The provider prescribes one unit of packed red blood cells to be administered to a client. To ensure the client's safety, which action will the nurse take during administration of blood products? 1. Stay with client during first 15 minutes of infusion. 2. Flush packed red blood cells with 5% dextrose and 0.45% normal saline. 3. Remove the intravenous catheter if a blood transfusion reaction occurs. 4. Administer the red blood cells through a percutaneously inserted central catheter line with a 20-gauge needle.

1. Stay with client during first 15 minutes of infusion.

Which action would the nurse take first when a client who is receiving a blood transfusion develops fever, chills, and low back pain? 1. Stop the blood transfusion and infuse saline. 2. Administer the prescribed antipyretic. 3. Obtain a prescription for an antihistamine. 4. Notify the blood bank about the symptoms.

1. Stop the blood transfusion and infuse saline.

Which type of debridement would the health care provider schedule for a client who requires removal of large amounts nonviable tissue, quickly? 1. Surgical debridement 2. Autolytic debridement 3. Enzymatic debridement 4. Mechanical debridement

1. Surgical debridement

How would the nurse prepare an intravenous piggyback (IVPB) medication for administration to a client who has an established IV infusion? Select all that apply. One, some, or all responses may be correct. 1. Wear clean gloves to assess the IV site. 2. Flush the IV insertion site with 2 mL saline. 3. Place the IVPB at a lower level than the existing IV. 4. Use a sterile technique when preparing the medication. 5. Establish the flow rate for infusion.

1. Wear clean gloves to assess the IV site. 4. Use a sterile technique when preparing the medication. 5. Establish the flow rate for infusion.

The nurse is teaching a client about sleeping positions to follow to prevent pressure ulcers. Which statement made by the client indicates effective learning? Select all that apply. One, some, or all responses may be correct. 1."I should use pressure-relieving pads." 2. "I should place a rubber ring under the sacral area." 3. "I should place pillows between two bony surfaces." 4. "I should keep the head of the bed elevated above 30 degrees." 5. "I should keep my heels off the bed surface using a bed pillow under the ankles."

1."I should use pressure-relieving pads." 3. "I should place pillows between two bony surfaces." 5. "I should keep my heels off the bed surface using a bed pillow under the ankles."

Which age-related skin change occurs in older adult clients and increases their potential for developing pressure ulcers? 1. Atrophy of the sweat glands 2. Decreased subcutaneous fat 3. Stiffening of the collagen fibers 4. Degeneration of the elastic fibers

2. Decreased subcutaneous fat

A client with a spontaneous pneumothorax asks, "Why did they put this tube into my chest?" Which information would the nurse provide about the purpose of the chest tube? 1. It checks for bleeding in the lung. 2. It monitors the function of the lung. 3. It drains fluid from the pleural space. 4. It removes air from the pleural space.

4. It removes air from the pleural space.

Which statement is correct regarding negative pressure wound therapy? Select all that apply. One, some, or all responses may be correct. 1. A suction pump is used. 2. Necrotizing infections are treated. 3. Oxygen is administered under high pressure. 4. A low-voltage current is applied to a wound area. 5. Chronic ulcers are reduced by removing fluids from the wound.

1. A suction pump is used. 5. Chronic ulcers are reduced by removing fluids from the wound.

When a client who is receiving a potassium infusion via a peripheral intravenous (IV) site reports a burning sensation above the IV site, which action would the nurse take first? 1. Check the IV access for a blood return. 2. Apply warm compresses to the affected extremity. 3. Slow the IV infusion until the burning sensation is gone. 4. Request an oral supplement from the primary health care provider.

1. Check the IV access for a blood return.

Arrange the steps for the collection of a urine sample from a client with an indwelling catheter in correct order.

1.Clamp drainage tubing. 2.Attach a sterile syringe. 3.Aspirate the urine. 4.Remove the clamp.

A client has undergone pelvic surgery, and the nurse removes the catheter in a week according to instructions. In the follow-up within several hours, which finding in the client indicates a need for reinsertion of catheter? 1. Anuria 2. Polyuria 3. Retention 4. Incontinence

3. Retention

A 2-year-old toddler is to have intravenous (IV) antibiotic therapy. Which action will the nurse take to prevent the child from pulling out the IV line? 1. Keep the arms restrained. 2. Tell the child not to touch the IV site. 3. Cover the IV site with a protective device. 4. Have the parent hold the child continuously.

3. Cover the IV site with a protective device.

A client has a tracheostomy tube attached to a tracheostomy collar for the delivery of humidified oxygen. What is the primary reason that suctioning is included in the client's plan of care? 1. Humidified oxygen is saturated with fluid. 2. The tracheostomy tube interferes with effective coughing. 3. The inner cannula of the tracheostomy tube irritates the mucosa. 4. The weaning process increases the amount of respiratory secretions.

2. The tracheostomy tube interferes with effective coughing

Which actions will the nurse include when doing tracheostomy care? Select all that apply. One, some, or all responses may be correct. 1. Suction the client before starting tracheostomy care. 2. Use sterile technique when cleaning the inner cannula. 3. Use sterile cotton-tipped swabs to clean the inner cannula. 4. Don sterile gloves before removing the inner cannula. 5. Use hydrogen peroxide to clean the skin around the stoma.

2. Use sterile technique when cleaning the inner cannula. 4. Don sterile gloves before removing the inner cannula.

Which intervention is most beneficial in preventing a catheter-associated urinary tract infection in a postoperative client? 1. Pouring warm water over the perineum 2. Ensuring the patency of the catheter 3. Removing the catheter within 24 hours 4. Cleaning the catheter insertion site

3. Removing the catheter within 24 hours

A postoperative client has 180 mL of urine in the urinary drainage bag from the past 8 hours. For which condition would the nurse monitor? 1. Renal failure 2. Liver cirrhosis 3. Diabetes mellitus 4. Rheumatoid arthritis

1. Renal failure

At which site would the nurse obtain a sterile urinalysis from a client with an indwelling catheter? 1. Tubing injection port 2. Distal end of the tubing 3. Urinary drainage bag 4. Catheter insertion site

1. Tubing injection port

The nurse is collecting the urine specimen of a client who has an indwelling catheter. Arrange in order the procedure involved in the collection of urine. In which order would the nurse perform the following actions?

1.Apply a clamp to the drainage tubing distal to the injection port. 2.Clean the injection port with an antiseptic. 3.Attach a 5-mL sterile syringe into the port. 4.Aspirate the quantity of the urine required. 5.Inject the urine sample into sterile specimen container. 6.Remove the clamp to resume the drainage. 7.Dispose of the syringe.

To prevent potential aspiration, which technique would the nurse use when cleaning a tracheostomy tube that has a nondisposable inner cannula? 1. Apply precut dressing around the insertion site with the flaps pointing upward. 2. Replace the tube with a sterile obturator. 3. Use sterile cotton balls to cleanse the outer cannula. 4. Remove the cannula after the high-volume, low-pressure cuff has been deflated.

1. Apply precut dressing around the insertion site with the flaps pointing upward.

The nurse instructs a client about safety measures and precautions when taking care of a pressure ulcer. During a follow-up visit, the nurse finds increased tissue necrosis with damaged capillary beds. Which actions by the client would the nurse expect are the reason for the client's condition? Select all that apply. One, some, or all responses may be correct. 1. Massaging the reddened skin areas 2. Placing pillows between two bony surfaces 3. Using donut-shaped pillows for pressure relief 4. Keeping the head of the bed below 30 degrees 5. Using a bed pillow under the ankles to keep the heels off the bed surface

1. Massaging the reddened skin areas 3. Using donut-shaped pillows for pressure relief

Which evidenced-based nursing intervention links to reducing catheter associated urinary tract infections (CAUTIs) in clients requiring long-term indwelling catheters? 1. Perform catheter care twice a day. 2. Replace the catheter on a routine basis. 3. Administer cranberry tablets three times a day. 4. Administer prophylactic antibiotics twice a day for the duration of the catheter placement.

1. Perform catheter care twice a day.

Which key feature is associated with a stage 2 pressure ulcer? 1. Presence of nonintact skin 2. Development of sinus tracts 3. Damage to the subcutaneous tissues 4. Appearance of a reddened area over a bony prominence

1. Presence of nonintact skin

Ten minutes after the initiation of a blood transfusion, a client reports chills and flank pain. Which nursing action would be performed first? 1. Stop the transfusion. 2. Obtain the vital signs. 3. Notify the health care provider. 4. Maintain the flow with normal saline.

1. Stop the transfusion.

A client anticipates removal of his or her chest tube with angst. Which diagnostic procedure does the nurse discuss when determining when to remove a client's chest tube? 1. The client tolerates disconnection from the chest tube's drainage system for 24 hours. 2. A chest x-ray examination occurs before removal to determine lung reexpansion. 3. A required arterial blood gas occurs to determine sustained oxygenation status. 4. The nurse will sedate the client 30 minutes before the scheduled procedure.

2. A chest x-ray examination occurs before removal to determine lung reexpansion.

Sterile warm saline soaks three times a day are prescribed for a client with cellulitis from a puncture wound. The primary nurse places a clean basin, washcloth, and protective pad at the bedside in preparation for the soak but is unable to continue the procedure. Which step would the new nurse assigned to complete the soak do? 1. Continue the procedure as started. 2. Collect new supplies before starting. 3. Discuss the type of soak with the primary health care provider. 4. Report the primary nurse to the unit's nurse manager.

2. Collect new supplies before starting.

Which nursing action is appropriate when suctioning the secretions of a client with a tracheostomy? 1. Use a new sterile catheter with each insertion. 2. Initiate suction as the catheter is being withdrawn. 3. Insert the catheter until the cough reflex is stimulated. 4. Remove the inner cannula before inserting the suction catheter

2. Initiate suction as the catheter is being withdrawn.

A client has chest tubes attached to a chest tube drainage system. Which intervention would the nurse perform when caring for this client? 1. Clamp the chest tubes when suctioning. 2. Palpate the surrounding area for crepitus. 3. Change the dressing daily using aseptic technique. 4. Empty the drainage chamber at the end of the shift.

2. Palpate the surrounding area for crepitus.

The registered nurse (RN) is teaching a nursing student about how to safely use a urinary catheter. Which statement made by the nursing student indicates ineffective learning? 1. "I will avoid the pooling of urine in the tubing." 2. "I will avoid prolonged clamping of the tubing." 3. "I will avoid draining urine from the tubing before ambulation." 4. "I will avoid raising the drainage tube above the level of the bladder."

3. "I will avoid draining urine from the tubing before ambulation."

A client admitted with urinary retention has an indwelling urinary catheter prescribed. Which action would the nurse implement to prevent the client from developing a urinary tract infection? 1. Assess urine specific gravity. 2. Collect a weekly urine specimen. 3. Maintain the prescribed hydration. 4. Empty the drainage bag once a day.

3. Maintain the prescribed hydration.

Which action would the nurse take to determine patency of the chest tube and closed chest drainage system in a client after left lower lobectomy? 1. Milk the chest tube toward the drainage unit. 2. Check the amount of bubbling in the suction control chamber. 3. Observe for fluctuations of the fluid in the water-seal chamber. 4. Assess for extent of chest expansion in relation to breath sounds.

3. Observe for fluctuations of the fluid in the water-seal chamber.

A client has a closed chest drainage system in place. How would the nurse determine the amount of chest tube drainage? 1. Aspirate the drainage from the collection chamber. 2. Clamp the chest tube and empty the fluid from the collection chamber. 3. Refer to the date and time markings on the outside of the collection chamber. 4. Replace the existing system with a new one to access the drainage in the existing system.

3. Refer to the date and time markings on the outside of the collection chamber.

A client has a chest tube in place for treatment of a pneumothorax. Upon entering the client's room, the nurse finds the client in respiratory difficulty, with the chest tube separated from the drainage system. Which action would the nurse take? 1. Notify the rapid response team. 2. Obtain a new sterile drainage system. 3. Use two clamps to close the drainage tube. 4. Reconnect the client's tube to the drainage system

4. Reconnect the client's tube to the drainage system

Which infection prevention technique would be appropriate for the nurse to include when teaching a client being discharged with an indwelling catheter? 1. Once a day, clean the tubing with a mild soap and water, starting at the drainage bag and moving toward the insertion site. 2. After cleaning the catheter site, it is important to keep the foreskin pushed back for 30 minutes to ensure adequate drying. 3. Clean the insertion site daily using a solution of 1 part vinegar to 2 parts water. 4. Replace the drainage bag with a new bag once a week.

4. Replace the drainage bag with a new bag once a week.

Which action would the nurse include when performing tracheostomy care on a client receiving mechanical ventilation? Select all that apply. One, some, or all responses may be correct. 1. Using hydrogen peroxide 2. Inserting a catheter without suction 3. Placing the client in the recumbent position 4. Rinsing the inner cannula with normal saline 5. Changing both tracheostomy ties at same time

4. Rinsing the inner cannula with normal saline

The day after a client has a cesarean birth, the indwelling catheter is removed. Which finding would indicate that urinary function has returned? 1. The client has 90 mL of residual urine after voiding. 2. The client's daily urinary output is at least 1500 mL. 3. The client's urinalysis indicates that no bacteria are present. 4. The client voids 300 mL of urine within 4 hours of catheter removal.

4. The client voids 300 mL of urine within 4 hours of catheter removal.

The nurse is caring for a client who has a tracheostomy tube and is receiving mechanical ventilation. The plan of care for the tube would include which nursing intervention? 1. Verify that an inner cannula is in place. 2. Change the tracheostomy tube every week. 3. Clean the tracheostomy once a day. 4. Verify that a low-pressure cuff is in place.

4. Verify that a low-pressure cuff is in place.

Which intervention would be included in the plan of care for the prevention of a pressure injury? 1. Positioning a client directly on the trochanter 2. Keeping the client's skin directly off plastic surfaces 3. Keeping the head of the bed elevated above 30 degrees 4. Placing a rubber ring or donut under the client's sacral area

2. Keeping the client's skin directly off plastic surfaces

Which complication would the nurse suspect in the client who returns to the unit after an abdominal hysterectomy with an indwelling urine catheter present and sanguineous urine in the collection bag? 1. An incisional nick in the bladder 2. A urinary infection from the catheter 3. Disseminated intravascular coagulopathy 4. Uterine relaxation with increased bleeding

1. An incisional nick in the bladder

When caring for a client who has hemopneumothorax and a chest tube, which prescribed action by the health care provider would the nurse question? 1. Autotransfuse the blood in the collection chamber after 6 hours. 2. Disconnect the drainage system from suction to ambulate the client. 3. Add sterile water to the suction control chamber to maintain 20 cm of suction. 4. Use a dressing impregnated with petroleum jelly around the chest tube insertion site.

1. Autotransfuse the blood in the collection chamber after 6 hours.

A client undergoes anterior and posterior surgical repair of a cystocele and rectocele and returns from the postanesthesia care unit with an indwelling catheter in place. Which are the reasons for the catheter? Select all that apply. One, some, or all responses may be correct. 1. Discomfort is minimized. 2. Bladder tone is maintained. 3. Retention of urine is prevented. 4.Pressure on the suture line is relieved. 5. Hourly urine output can be easily measured.

1. Discomfort is minimized 3. Retention of urine is prevented. 4.Pressure on the suture line is relieved.

A client is admitted with multiple injuries as a result of an accident. A tracheostomy was performed. While the nurse is caring for this client, the client coughs, expelling the tracheostomy tube onto the bed. Which action would the nurse take? 1. Hold the tracheostomy open with a tracheal dilator and call for assistance. 2. Insert an obturator into the tracheostomy and gently reinsert the tracheostomy tube. 3. Pick up the tracheostomy tube from the bed and replace it until a new tube is available. 4. Obtain a new tracheostomy tube, prepare the new holder, and insert the tube using the obturator.

1. Hold the tracheostomy open with a tracheal dilator and call for assistance.

Which impending problem would the nurse suspect when caring for a client with bloody urine in the indwelling catheter collection bag, after an emergency cesarean birth? 1. Incisional nick in the bladder 2. Urinary infection from the catheter 3. Uterine relaxation with increased lochia 4. Disseminated intravascular coagulopathy

1. Incisional nick in the bladder

The nurse is caring for a client who experienced a crushing chest injury. A chest tube is inserted. Which observation indicates a desired response to this treatment? 1. Increased breath sounds 2. Increased respiratory rate 3. Crepitus detected on palpation of the chest 4. Constant bubbling in the drainage collection chamber

1. Increased breath sounds

Which action will the nurse take to check for subcutaneous emphysema in a client with a chest tube? 1. Palpate around the tube insertion sites for crepitus. 2. Auscultate the breath sounds for crackles and atelectasis. 3. Observe the client for the presence of a barrel-shaped chest. 4. Compare the length of inspiration with the length of expiration.

1. Palpate around the tube insertion sites for crepitus.

The nurse is caring for a client with a tracheostomy. Which action would the nurse implement when performing tracheal suctioning? 1. Preoxygenate the client before suctioning. 2. Employ gentle suctioning as the catheter is being inserted. 3. Loosen the client's secretions before suctioning by instilling saline. 4. Ensure that the cuff of the tracheostomy is inflated during suctioning

1. Preoxygenate the client before suctioning.

Which action by the nurse would best facilitate communication for a client with a partial laryngectomy and tracheostomy in the immediate postoperative period? 1. Provide a means for the client to write. 2. Allow time to lip read what the client says. 3. Deflate the cuff on the tracheostomy tube to allow verbalization. 4. Remind the client that speech is possible after partial laryngectomy.

1. Provide a means for the client to write.

The nurse is assessing four clients for risk factors for developing a pressure injury. List in order of priority the client with the greatest risk for developing a pressure injury to the client with the smallest risk.

1.70-year-old man, admitted with metastatic bone cancer, weighing 80 lbs (36.36 kg), dehydrated, and bed bound 2.62-year-old woman, admitted because of a cerebrovascular accident (CVA), left hemiplegia, incontinent of urine and stool, and transfers to a chair via a mechanical lift 3.25-year-old man, diagnosed with sepsis, average height and weight, developmentally disabled, unable to communicate except with grunts, incontinent of urine, and ambulatory 4.78-year-old woman, admitted to the hospital for knee replacement surgery, no sensory impairment, continent, and ambulatory

The nurse is suctioning a client's tracheostomy. What is the correct order of nursing actions when performing this procedure?

1.Auscultate the lungs and check the heart rate. 2.Prepare by turning suction on to between 80 and 120 mm Hg pressure. 3.Hyperoxygenate using 100% oxygen. 4.Don sterile gloves. 5.Guide the catheter into the tracheostomy tube using a sterile-gloved hand.

A nurse is caring for a client with a pneumothorax who has a chest tube attached to a closed chest drainage system. If the chest tube and closed chest drainage system are effective, which type of pressure will be reestablished? 1. Neutral pressure in the pleural space 2. Negative pressure in the pleural space 3. Atmospheric pressure in the thoracic cavity 4. Intrapulmonic pressure in the thoracic cavity

2. Negative pressure in the pleural space

The nurse is to initiate an intravenous line and applies the tourniquet to the selected site. The nurse would release the tourniquet at which time? 1. After cleaning the insertion site 2. When the needle enters the vein 3. As soon as the needle pierces the skin 4. After the device is secured with tape

2. When the needle enters the vein

Which finding best indicates that the chest tube for a client with a pneumothorax may be discontinued? 1. Clear breath sounds heard in both lungs 2. Oxygen saturation reading is higher than 90% 3. Absence of bubbling in the water-seal chamber 4. Full re-expansion of the lungs seen on chest x-ray

4. Full re-expansion of the lungs seen on chest x-ray

Which nursing action would the nurse perform first if nerve damage is suspected during an intravenous catheter insertion? 1. Clean the exit site with alcohol. 2. Apply a warm compress. 3. Elevate the affected limb. 4. Immediately stop the insertion if the client reports extreme pain

4. Immediately stop the insertion if the client reports extreme pain