Cumulative Quiz 2
The nurse is teaching a client with a new colostomy about colostomy bag hygiene. The nurse knows the education has been successful when the client says:
"I will replace my colostomy bag with a new bag every 3-7 days."
A nurse is feeding a client. Which statement would help a person maintain dignity while being fed?
"What part of your dinner would you like to eat first?"
A nursing documented the following input during her shift -400 mL Normal Saline via IV, 2 cups of ice chips, and 8 ounces of tea. Calculate the total intake in milliliters. Enter NUMBER ONLY.
880
A nurse is changing a client's peripheral IV dressing. Which of the following is a recommended step in this procedure?
Apply antiseptic solution, such as chlorhexidine to the site in order to disinfect
A nurse maintains the head of the bed elevated 30 degrees for a client who is receiving continuous tube feedings to prevent:
Aspiration
Which of the following statements accurately describes a recommended guideline when using venipuncture to collect a venous sample for routine testing?
Avoid areas that are edematous, paralyzed, or are on the same side as a mastectomy.
A physician orders the following lab tests: BMP, CBC, blood cultures, and a PT/PTT. Which test should be drawn first?
Blood cultures
A nurse is assessing urine in an indwelling catheter bag for signs of infection. What urine characteristic would give the nurse concern for possible catheter associated urinary tract infection (CAUTI)?
Cloudy urine
A nurse is assessing the stoma of a client with an ostomy. What would the nurse assess in a normal, healthy stoma?
Dark red and moist
A nurse inspecting a client's IV site notices redness and swelling at the site. What would be the most appropriate nursing intervention for this situation? Group of answer choices
Discontinue the IV and relocate to another site
A nurse has finished giving care to a client who has a communicable respiratory infection. Which of the following pieces of personal protective equipment should the nurse remove first?
Gloves
A nurse receives an order to apply graduated compression stockings for a client at risk for venous thromboembolism. How should the nurse apply the stockings?
If the client was sitting up, have him or her lie down and elevate feet for 15 minutes before applying stockings.
A nurse assesses the abdomen of a client before and after administering a small-volume cleansing enema. What condition would be an expected finding?
Increased bowel sounds
A physician orders the collection of a sputum specimen from a client with a suspected bacterial infection. Which of the following actions best ensures a useable specimen?
Instruct the client to inhale deeply and then cough.
A nurse is using venipuncture to collect a venous blood sample from a client who has a clotting disorder. What would be the appropriate intervention for this client?
Maintain firm pressure on the venipuncture site for at least 5 minutes after withdrawing the needle.
A client who has a bacterial infection develops an abscess that needs to be drained. What drainage system would most likely be used in this situation?
Penrose drain
A nurse is caring for a client with an ileostomy. The nurse knows to assess for what potential complication due to stool characteristics from an ileostomy.
Skin breakdown around stoma
A nurse is using a portable bladder scanner to assess for urinary retention. The nurse knows the client should be in what position for the scan to be most accurate?
Supine
A nurse is applying the principles of Standard and Contact Precautions in the care of a hospital client. What action violates these principles?
The nurse removes her gown and then removes her gloves
A client is having difficulty having a bowel movement on a bedpan. What is the physiologic reason for this problem?
The position does not facilitate downward pressure.
When obtaining a stool specimen, the nurse should use a sterile container.
True
A nurse assessing a client's respiratory status gets a weak signal from the pulse oximeter. The client's other vital signs are within reference ranges. What is the nurse's best action?
Warm the client's hands and try again
A nurse's gloves became soiled while providing morning care for a client. Which of the following actions best demonstrates that the nurse applied principles of infection control?
after removing the glove on the non dominant hand, hold the removed glove in the remaining gloved hand
A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene?
placing the tourniquet on the upper arm for 2 minutes
Which of the following clinical characteristics should the nurse recognize as a rationale for collecting a blood culture?
A client develops a sudden fever
A nurse is testing blood glucose levels of a client with a history of diabetes. The nurse has performed hand hygiene, checked the order, informed the client, and turned on the meter. After removing a test strip from the vial, what action should the nurse perform next?
Confirm that the strip and the meter share the same code
A nurse using a pulse oximeter to measure a client's SpO2 obtains a reading of 95%. What is the nurse's most appropriate action?
Document this expected assessment finding.
A client has undergone abdominal surgery for the treatment of cancer and is recovering with a Hemovac drain in place. Which of the following nurse's actions was not appropriate?
Leaving the drain open for 5 to 7 minutes to ensure full drainage.
The nurse recognizes a need to promote venous return and prevent complications related to venous stasis in a client with decreased activity. What action by the client best accomplishes this goal?
Leg exercises
A sterile urine specimen for culture and sensitivity has been ordered for a client who has an indwelling urinary catheter. How should a nurse obtain this sample?
Withdraw several milliliters of urine from the port on the collection tubing, using a syringe.