Chapter 22 and 23 practice questions

The nurse informs a client that a Papanicolaou smear will be done at the next scheduled clinic visit, and the nurse provides instructions to the client regarding preparation for this test. Which statement by the client indicates an understanding of the procedure?

"If I have my period at the time of my next scheduled visit, I will not be able to have the test done."

On evaluation of the patient after a venipuncture, the nurse recognizes which finding to be unexpected? (Select all that apply)

2. A large lump is noted under the skin at the venipuncture site.

When is the best time to collect a sputum sample from a patient?

2. In the morning upon awakening

A patient has an indwelling urinary catheter. A sterile urine specimen has been ordered for culture and sensitivity. Which is the best method for the nurse to collect the urine specimen?

4. Aspirate 10 mL of urine with a sterile syringe from the tubing port after cleaning with alcohol.

What action should the nurse implement to reduce surgical wound infection?? (Select all that apply.)

4. Changing the dressing using sterile technique

Which nursing entry is the most complete in its description of a wound?

Incisional edges approximated without erythema or exudate; two 4 × 4s applied

The nurse is reinforcing teaching to a client about an upcoming colonoscopy procedure. The nurse should include in the instructions that the client will be placed in which position for the procedure?

Left Sims' position

What is the correct procedure for the wet-to-dry dressing method?

Place moist gauze into the wound and remove it when it is dry.

The health care provider has ordered an abdominal binder placed around a surgical patient with a new abdominal wound. What is the likely indication for this intervention?

Reduction of stress on the abdominal incision

The nurse finds that the patient's incision has eviscerated. What action should the nurse take? (Select all that apply.)

Replace dressings with sterile fluffy pads.

17. The health care provider has ordered all sutures on a patient with an abdominal hysterectomy be removed on the 5th postoperative day and Steri-Strips applied. During suture removal, the nurse notices the incision edges are slightly separating. What is the best action by the nurse?

Stop the suture removal, apply Steri-Strips where sutures already have been removed, and notify the health care provider.

A client is scheduled for blood to be drawn from the radial artery for an arterial blood gas (ABG) determination. The nurse assists with performing Allen's test before drawing the blood to determine the adequacy of which?

Ulnar circulation

The nurse reinforces instructions to a client who is to return to the primary health care provider's office in 1 week for a patch test to identify the allergen causing the dermatitis. The nurse provides which instruction to the client?

"Discontinue the prescribed antihistamine 2 days before the test."

The client has just undergone computed tomography (CT) scanning with a contrast medium. Which statement by the client demonstrates an understanding of post-procedure care?

"I should drink extra fluids for the remainder of the day."

A client who has undergone barium enema is being readied for discharge. The nurse determines that the client has understood discharge instructions when the client makes which statement?

"I will be sure the barium passes and watch for my stools to return to normal."

When obtaining a residual urine specimen, the nurse knows that it is important to catheterize the patient after the patient voids within which time frame?

1. 10 minutes

Because of loss of subcutaneous tissue and skin elasticity in older adults, which step of the venipuncture procedure will the nurse sometimes eliminate?

1. Application of the tourniquet before venipuncture

What are the traditional purposes of a wet-to-dry dressing? (Select all that apply.)

1. Débridement 5. Maintenance of moisture at the wound bed

In the assessment of a patient's urine sample, what will the nurse consider an abnormal finding? (Select all that apply.)

3. Bloody mucus

Which phrase best describes serous drainage?

3. Clear, watery plasma

The nurse is caring for the client who is going to have an arthrogram using a contrast medium. Which data collected by the nurse should be of highest priority?

Allergy to iodine or shellfish

The nurse reinforces what information to a client who is scheduled for an electromyogram (EMG)?

Electrodes will be inserted into the skeletal muscles.

An adult female client has a hemoglobin level of 10.8 g/dL (108 g/L). The nurse interprets that this result is most likely caused by which condition noted in the client's history?

Iron deficiency anemia

The nurse reinforces postoperative liver biopsy instructions to a client. Which should the nurse tell the client?

Lie on the right side for 2 hours.

A client who has been prescribed indomethacin for gout is asked to provide a stool sample for guaiac testing. The nurse explains that the purpose of the test is to make which determination?

Occult blood

A client with a history of gastrointestinal bleeding has a platelet count of 300,000 mm3 (300 × 109/L). The nurse should take which action after seeing the laboratory results?

Place the normal report in the client's medical record.

The nurse is preparing to care for a client following a lumbar puncture. The nurse plans to place the client in which position immediately after the procedure?

Prone with a pillow under the abdomen

A client is scheduled for a digital subtraction angiography (DSA). The nurse tells the client that the test is directed toward which outcome?

Providing information about the blood vessels

A client suspected of having an abdominal tumor is scheduled for a computed tomography (CT) scan with dye injection. The nurse should tell the client which information about the test?

The dye injected may cause a warm, flushing sensation.

A patient performing a fingerstick for blood glucose determination asks why the side of the fingertip is advised as the preferred site. Which is the best answer that the nurse will give to the patient?

The side of the finger is less responsive to pain than other sites.

Rank order the following instructions that the nurse would tell a female patient who needed to obtain a midstream urine specimen.

3. Perform hand hygiene before obtaining the specimen. 4. Clean the perineum by wiping from front to back. 1. Start voiding directly into the toilet. 5. Collect a small amount of urine in the container. 2. Discard the last of the stream of urine into the stool.

What is the first step when packing a wound?

3. Select gauze packing material.

An ultrasound of the gallbladder is scheduled for the client with a suspected diagnosis of cholecystitis. Which should the nurse explain to the client about this test?

3.The test requires the client to lie still for short intervals.

When the drainage in a Hemovac reservoir is emptied,which nursing action is essential for reestablishing the negative pressure within this drainage device?

3. Compress the reservoir and close the vent.

Rank order the instructions that would be given to the patient who is to collect a 24-hour urine specimen.

3. Explain the importance of collecting all voiding. . 4. Instruct the patient not to allow toilet tissue or stool to enter the collection container. 1. Place the collection container on ice. 2. Discard the first voided specimen and then collect the total volume of each void. 5. Collect each void in a urine hat and add to the larger collection container.

1. The patient has just returned from the postanesthesia care (PAC) unit. During report, the nurse is told that the patient has a Penrose drain in the left lower quadrant (LLQ). The patient asks why the drain is being used. What response by the nurse is most accurate?

. "Gravity is used to drain fluid from the area around the wound with the Penrose drai

A patient is scheduled for a barium enema study. Which instructions will the patient be given?(select all that apply)

. Maintain NPO status after midnight before the examination. 4. Monitor bowel movements after the procedure. 5. Increase fluid intake after the procedure.

What is the best indicator that a wound has become infected?

. Purulent drainage is coming from the wound area.

The nurse is caring for a client scheduled for magnetic resonance imaging (MRI). Which instruction does the nurse reinforce to the client?

.Earplugs can be worn if the noise from the machine is uncomfortable.

A pulmonary angiography is scheduled for a client suspected of having a pulmonary embolism. The nurse understands that which actions are an appropriate preprocedure care intervention? Select all that apply.

.Obtain a signed informed consent form. 2.Prepare the anticipated entry site for local anesthesia. 3.Inquire whether the client has any allergies to shellfish .Ask whether client has ever experienced an allergy to any contrast media.

The nurse has just received an order for electrocardiography. Arrange the following steps in the order that the nurse would perform them.

1. Perform hand hygiene and don clean gloves. 3. Position the patient lying supine. .4 Raise the side rail, and lower the bed to the lowest position. 5. Shave or clip hair if necessary. 6. Attach the leads to the patient. 2. Obtain the tracing

When providing care to a patient with a Hemovac drain, what actions are included in the plan of care?

1. Record the appearance of the drainage in the nursing progress notes and include the amount in the fluid output calculations.

A nursing student asks the nurse to explain the difference in testing between a midstream urine specimen and a urinalysis. Which explanation would answer the nursing student's question? (Select all that apply.)

1. The midstream specimen is used to determine the culture and sensitivity of the urine specimen. 5. The midstream specimen is the cleanest portion of the urine specimen.

A 46-year-old patient is seen by the health care provider for recurrent symptoms of cystitis. The patient is to provide samples for urine culture and sensitivity. Which is the best answer that the nurse can give to the patient when asked why the urine culture study has been ordered?

1. To identify the organism causing the infection

A client will undergo a barium swallow to confirm a diagnosis of a hiatal hernia. In preparation for the test, which instruction should the nurse provide the client?

1.Avoid eating or drinking after midnight before the test.

The nurse prepares a client for the lumbar puncture procedure by which interventions? Select all that apply.

1.Review the coagulation laboratory studies. 2.Observe the lower lumbar area for skin infections. 4.Check to see the client has a signed consent for the procedure.

The student nurse is changing a patient's dressing. What action indicates the need for further education? (Select all that apply.)

2. Clean the wound in circles toward the incision. 3. Free the tape by pulling it away from the incision. 4. Remove the soiled dressing with sterile gloves. 5. Apply the clean dressing with clean gloves.

A sputum specimen has been ordered for a patient admitted with possible pneumonia of the right lower lobe. Which is the best method for the nurse to use with a patient who cannot expectorate sputum on their own?

2. Nasotracheal suctioning

Which nursing action is essential before a chest radiograph is obtained?

2. Remove the patient's metal necklace.

During assessment of a patient after abdominal surgery, the nurse suspects internal hemorrhaging based on which finding?

2. The dressing is dry and intact, the patient's blood pressure has decreased, and pulse and respirations have increased.

Which patient is more at risk for wound dehiscence?

2. The patient who is obese

The nurse is assisting in performing an arterial blood gas (ABG) analysis on a client. The nurse initially implements which intervention after the blood gas is drawn to minimize the risk for uncontrolled bleeding?

2.Applying direct pressure to the site

The nurse has just confirmed that a client has been scheduled for a mammogram for the following week. The nurse reinforces that the client should take which actions? Select all that apply.

2.Avoid applying skin lotion on the day of the test. 3.Remove any necklaces before presenting for the procedure.

A client undergoing diagnostic testing for cancer is scheduled for magnetic resonance imaging (MRI). The nurse reinforces to the client which information about the procedure?

2.Expect the MRI machine to make loud noises.

A client with ascites is scheduled for a paracentesis. The nurse is assisting the primary health care provider (PHCP) with performing the procedure. Which position should the nurse assist the client into for this procedure?

2.Upright

The student nurse is correct when indicating which drain as providing suction-assisted drainage?

3. Penrose

The health care provider has ordered a stool specimen for blood that it is not possible to see with the naked eye. What does this examination detect?

4. Occult blood

. Which statement is correct in regard to the use of an abdominal binder?

4. The patient must have adequate ventilatory capacity

The nurse is assisting in preparing a client for a cardiac catheterization. The nurse understands that it is important to check the client's record for which history?

4.Allergy to shellfish

The nurse assists the primary health care provider in performing a lumbar puncture on a 3-year-old child with leukemia suspected of central nervous system (CNS) disease. In which position should the nurse place the child during this procedure?

4.Lateral recumbent with the knees flexed to the abdomen and head bent with the chin resting on the chest

A clinic nurse has given a client the materials needed to test the stool for occult blood as part of a routine screening for colorectal cancer. When the client asks the nurse whether there are any special precautions that must be followed in doing this test, the nurse tells the client to avoid eating which food for at least a day before performing the test?

4.Red meat

The client is having a lumbar puncture (LP) performed. The nurse should place the client in which position for the procedure?

4.Side-lying, with legs pulled up and chin to the chest

A client has had a bone scan procedure. The nurse determines that the client understands the elements of follow-up care if the client states which postprocedural care?

Drink plenty of water for a day or two following the procedure.

A 64-year-old patient who has newly diagnosed diabetes mellitus has been learning how to perform her own blood glucose monitoring. The patient has impaired circulation. What action can help to improve the specimen collection process?

Massage the hand before performing the specimen collection.

The health care provider has ordered the patient's wound be irrigated. What is the primary rationale for this procedure?

To remove debris from the wound