Foundations of care

The nurse is assisting with monitoring the functioning of a chest tube drainage system in a client who just returned from the recovery room after a thoractomy with wedge resection. Which findings with the nurse expect to note.

50 mL of drainage in the drainage collection chamber, the drainage system is maintained below, the clients chest, an occlusive dressing is in place over the chest tube, insertion site, punctuation of water in the tube of the water still chamber during inhalation and exhalation

The nurse is assigned to assist with caring for a client with esophageal varices, who had a sengstaken Blakemore tube inserted because other treatment measures were unsuccessful. The nurse would check the clients room to ensure that which priority item is that bedside.

A pair of scissors

The nurse is monitoring an adult client for postoperative complications, which is the most indicative of a potential postoperative complications that requires further observation

A urinary output of 20 mL in an hour

The emergency department nurse receives a telephone phone call and is formed that a tornado has hit a local residential area in numerous casualties have occurred the victims will be brought to the emergency department, which would be the initial nursing action

Activate the agency emergency response plan

The nurse enters a clients room and finds that the wastebasket is on fire. The nurse quickly assist the client out of the room, which is a next nursing action?

Activate the fire alarm

The nurse notes documentation that a client has conductive hearing loss. The nurse plans care, knowing that this kind of hearing loss can be caused by which circumstances? Select all that apply.

Acute otitis media with effusion A physical obstruction to the transmission of sound waves

The nurse enters the nursing lounge and discovers that a chair is on fire the nurse activate the alarm closes the lounge door in obtains the fire extinguisher to extinguish the fire. The nurse pulls the pen on the fire extinguisher, which is the next action for the nurse to perform.

Aim at the base of the fire

A license practical nurse attends a session about bioterrorism agents, including Anthrax. which statement by an attendee demonstrates the need for further teaching about anthrax?

Anthrax bacteria produces a neurotoxin, leading to a serious possible fatal paralysis

The nurse obtains the vital signs on a postoperative client who just returned to the nursing unit. The clients blood pressure is 100/60 MM Hg the pulse is 90 bpm and the respirations is 20 breaths per minute on the basis of these findings which actions would the nurse take select all that apply

Ask how the client feels and inquire about any feelings of dizziness, review the client record to determine time and type of analgesic last received, review the client record to note the vital signs taken in the post anesthesia care unit

The nurse is caring for a client who is scheduled for surgery. The client states concern about the surgical procedure. How would the nurse initially address the clients concerns?

Ask the client to discuss information known about the planned surgery

A client arrives to the surgical nursing unit after surgery. What would the initial nursing action after surgery?

Assess patency of the airway

The nurse is assisting in planning care for a client with a chest tube. The nurse would suggest to include which interventions in the plan.

Be sure all connections remain airtight, be sure all connections are taped and secure, monitor closely for tubing that is kinked or or obstructed

A mother calls neighborhood nurse and tells the nurse that her three year old child has just ingested liquid furniture polish which action would the nurse instruct the mother to take first

Call the poison control center

The nurse is caring for a postoperative client who has a Jackson-Pratt drain inserted into the surgical wound which action would the nurse take in the care of the drain select all that apply

Check the drain for patency, check the drain is decompressed, observed for bright, red, bloody drainage, maintain aseptic technique when emptying, emptied the drain when it is half full, and every 8 to 12 hours

The nurse is preparing to administer a medication through a NG tube that is connected to suction. Which interventions would be included to accurately administer the medication.

Clamp the NG tube for 30 minutes and after medication administration, before medication administration, very correct placement of tube, flush the NG tube with Celine before, and after medication administration, discontinued the suction from the tube during administration of medication

The nurse is reviewing the clients health record and notes that the client elicited a positive Romberg sign. Based on this finding the nurse would institute which intervention.

Collect data to determine factors for fall risk, instruct the client to ask for assistance when getting up to walk

The nurse is a sign to assist with caring for a client who has a chest tube. The nurse notes fluctuations on the fluid level and the water salt chamber based on this observation which action would be appropriate.

Continue to monitor

The nurse is assigned to assist the primary healthcare provider with the removal of a chess to which interventions with the nurse anticipate performing during this procedure

Cover the site with an occlusive dressing after the tube is removed, have a client perform the valsalva maneuver as the chest tube is pulled out.

The nurse learns in report that a client is exhibiting cheyne-strokes, respirations based on these data, which action is most appropriate for the nurse to take initially?

Determine the clients ability to follow verbal commands

The nurse is preparing to administer an intermittent tube feeding to a client. The nurse aspirates, 90 mL of residue from the tube. What would the nurse do?

Document the amount of residue, reinstall the residue and administer the feeding

The nurses told that in assigned client will have a fenestrated tracheostomy tube inserted. The nurse plans care, knowing that which facts are true with the use of a fenestrated tracheostomy tube

Enables the client to speak, must have the cuff deflated when capped

A license practical nurse is preparing to assist a registered nurse with removing a NG tube from the client which interventions would be included in the procedure

Explain the procedure to the client, ask the client to take a deep breath and hold, pull the tube out in one continuous steady motion, remove the device or tape, securing the tape from the nose

Why collecting data related to the cardiac system on a client the nurse here's a murmur which best describes the sound of a heart murmur?

Gentle blowing, or swooshing noise

The nurse is assisting in creating a plan of care for a client who is scheduled for surgery. The nurse would include which activities in the nursing care plan for the client on the day of surgery. Select all that apply.

Have a client void before surgery,Determine that the client has signed the informed consent for the surgical procedure

The nurse is assisting with the insertion of a NG tube into a client. Nurse needs to place the client in which position for insertion.

High Fowlers position

The nurse is reinforcing home care instructions to a client and family regarding care after left cataract surgery with lens implant, which statements made by the client indicates an understanding of the instructions select all that apply

I will not sleep lying on my left side, I will sit at the table and eat breakfast, I will sit in my recliner with my feet elevated, I will not lift anything heavy according to my surgeons order

The nurse is planning to begin a continuous to feeding on a client with the NG tube which interventions with the nurse perform before initiating the feeding

Irrigate the NG tube with Celine, explain the procedure to the client, elevate the head of the bed to 45°

The nurse is collecting data from a client who is scheduled for surgery in one week in the ambulatory care surgical center which pertinent client data. Would the nurse report to the surgeon before the surgery.

Is allergic to penicillin, quit smoking, three months earlier, wonders if the surgery could cause incontinence, history of deep venous thrombosis in right leg, 10 years earlier

After a client undergoes, a liver, biopsy, the nurse places the client in the prescribed right side, lying position. The client understands that the purpose of this intervention is to accomplish which outcome.

Limit, bleeding from the biopsy site

The nurse is preparing to administer an intermittent tube feeding to a client with the NG tube the nurse checks, the residue and obtains an amount of 200 mL which actions with the nurse take

Listen to the clients bowel sounds, question the client regarding nausea, determine whether the client has abdominal distention, hold the feeding after flushing the tubing with 30 mL of saline

The nurse is assisting to perform a focused data collection process on a client who is complaining of symptoms of a cold, a cough, and lung congestion which would the nurse include for this type of data collection select all that apply.

Listening to lung sounds, obtaining the clients temperature, obtaining information about the clients respirations.

The nurse is checking a client surgical incision and notes an increase in the amount of drainage a separation of the incision line in the appearance of underlying tissue. Which action would the nurse take to deal with this event select all that apply

Notify the registered nurse, and the surgeon, apply a sterile dressing, soaked with normal saline to the wound

The nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the client becomes restless and tachycardic, which actions with the nurse take select all that apply

Notify the registered nurse, discontinue suctioning until the client stabilized

The nurse is a sign to care for a client who has a chest tube. The nurses told to monitor the client for crepitus. Which method would be used to monitor the client for crepitus?

Palpitating the skin around the chest and neck for a crackling sensation

The nurse supplies, wrist restraints prescribed to prevent a client from pulling out a NG tube. How would the nurse determine that the restraints are not too constructive?

Place two fingers under their strength to determine snugness

The nurse has assisted in inserting a NG tube in a client and is checking for the correct placement of the NG tube, which is the most reliable data to ensure that the end of the tube is in the stomach

Placement is verified on x-ray

The nurse monitors the four day postoperative client who underwent abdominal surgery. Vital signs are temperature of 100.2°F pulse 104 bpm respirations 22 breaths per minute blood pressure 128/74 MM Hg oxygen saturation is 93% on room air, the client feels tired and has a productive cough. Find crackles are audible in the basis of the lungs posteriorly the nurse considers the client has developed which post operative problem.

Pneumonia

The nurse is reinforcing instructions for a client and how to perform a testicular self-examination, which instructions would the nurse include select all that apply

Preform, TSE after a shower or bath, preform TSE on the same day each month, perform TSE by rolling, each testicle between the thumb and fingers

The nurse is caring for a client with a healthcare associated infection caused by MRSA contact precautions are prescribed for the client. The nurse prepares to irrigate the wound and apply a new dressing which protective interventions with a nurse used to perform this procedure. Select all that apply.

Put on a mask, Don gown and gloves, wear a pair of protective goggles

A Spanish-speaking. Client arrives at the triage desk in the emergency department and states to the nurse no speak English need interpreter, which action must the nurse take

Seek an interpreter from the hospitals interpreter services

The nurse is assisting with caring for a client after a craniotomy. Which are the positions that would be used for the client

Semi-Fowlers position, with the foot of the bed flat

The nurse is assigned to assist with caring for a client after cardiac catheterization performed through the left femoral artery. The nurse needs to plan to maintain bed rest for this client in which position.

Supine with head elevation, no greater than 30°

A client has just returned to a nursing unit after an above knee amputation on the right leg. The nurse needs to plan to place the client in which position.

Supine with the residual limb supported with pillows

The nurse is preparing to assist the healthcare provider to test the extraocular movements in the client and muscle weakness in the eyes nurse anticipate that which physical assessment technique will be done

Testing the six cardinal positions of gaze

A client is being prepared for a thoracentesis. The nurse reinforces instructions with the client given by the registered nurse which points would be included in the instructions.

The client leans over a bedside table, the client would sit on the edge of the bed, a timeout is performed before the procedure, a local anesthetic is administered before the procedure

The nurse notes the physical assessment findings for a client with a diagnosis of possible meningitis which findings with the nurse expect to observe because of meningeal irritation select all that apply

The client reports stiffness and soreness in the neck area, the client reports pain in the vertebral column and passively, flexes the hip and knee in response to neck flexión, the client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended

The nurse is administering a cleansing enema to a client with a fecal impaction before administering the enema. The nurse asked the client to assume a modified left lateral recumbent position. The nurse explains that this positioning is preferred because of which reason.

The enema will flow into the bowel easily

The nurse checks the postoperative client for signs of infection. Which observations are indicative of a potential infection? Select all that apply.

The presence of purulent drainage, and tender firmness palpable around the incision.

The nurse obtains a prescription to restrain a client be using a belt restraint and instructs the assistive personnel to apply the restraint which observation is made by the nurse indicates, unsafe application of the restraint

The restraint straps are safely secured to the side rails

The nurse is preparing to reposition a dependent client who weighs more than 250 pounds which interventions with a nurse used to move this client select all that apply

Use a friction, reducing slide sheet, use a mechanical lift to move the client, keep elbows, close, and work close to the body, obtain assistance of a second caregiver to assist with mechanical aids

The nurse is assisting with creating a plan of care for a client with an internal radiation implant, which would be included in the plan of care select all that apply

Wearing gloves when emptying the clients bed pan, keeping all linens in the room, until the implant is removed, wearing a film badge when in the clients room, wearing a lead apron when providing direct care to the client

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which signs would the nurse expect to note in the health record when collecting data related to the respiratory system for this client?

Wheezes and use of accessory muscles

The nurse is inserting an indwelling urinary catheter into a male client as the catheter is inserted into the Yuridia you're in begins to flow into the tubing when would the nurse and inflate the balloon?

When the catheter is advanced to the point of bifurcation

The nurse would institute which interventions for a client diagnosed with C diff select all that apply

wear gloves and gown, while in the room, caring for the client, use soap and water, not alcohol-based hand rub for hand hygiene