Module 3
A client is receiving a continuous tube feeding. Which accurately describes an aspect of this procedure?
A feeding pump is used for a continuous feeding.
Which actions by the nurse are appropriate when administering a vaginal cream? Select all that apply.
> Insert the vaginal applicator directing it downward and backward. > Perform perineal care cleansing from just above the vaginal orifice downward. > Keep the plunger applicator fully depressed until removed from the client.
The client has had surgery to repair a left hip fracture. The client is asking to use the bedpan. How should the nurse assist the client onto the bedpan? Select all that apply.
> Turn the client onto the unaffected leg to place the bedpan. > Ensure the client's buttocks are resting on the shallow rim of bedpan. > Seek assistance from another nurse to support the affected leg.
What documentation is important for the nurse to include when administering a retention enema? Select all that apply.
> amount, consistency, and color of stool > length of time retained by the client > client's reaction to the procedure > pain assessment rating by the client > amount and type of enema solution used
Which clients does the nurse anticipate needing a retention enema? Select all that apply.
> client with intestinal parasites and a prescription for anthelmintic enema > client with cirrhosis and a prescription for neomycin enema > client with bowel distention secondary to flatus > Postoperative client with constipation
The nurse is preparing to administer medications to a client with a gastric tube. What information should the nurse check before administering any medication through the gastric tube? Select all that apply.
> client's allergies > if medication should be given on full or empty stomach > whether tube feedings should be held
The nurse is caring for a client who asks to use a bedside commode. Prior to assisting the client, what things are important for the nurse to assess? Select all that apply.
>Assess client for weakness or unsteady gait., >Check for the presence of drains and IV fluid lines., >Evaluate the client for any functional limitations.
The nurse is caring for a client with a gastrostomy tube and notes a patchy, red rash at the insertion site. Which action would be most appropriate to address this concern?
Notify the health care provider for a prescription to apply an antifungal powder.
The nurse is caring for a client who has a prescription for strict intake and output measurements. The client wants to use the bedside commode. What is most important for the nurse to instruct the client?
Toilet tissue should not be placed in the commode as it may affect accurate measurement.
The nurse is helping to clean a female client who has urinated into a bedpan. What is the recommended guideline for this action?
Use toilet paper to wipe the client from the pubic area to the anal area.
What should the nurse ask the client to do before inserting a vaginal cream medication?
Void to empty the bladder to lessen discomfort.
A nurse is caring for a client with a gastrostomy tube and observes that a large amount of drainage is leaking from the tube. On inspection the nurse finds a great deal of slack in the tube. Which action should the nurse take next?
Apply gentle pressure to the tube while pressing the external bumper closer to the skin.
The nurse needs to collect a stool specimen for culture from a client. The client has been having watery stools for several days and asks if a sample can still be tested since stool is not formed. What is the best response by the nurse?
"As long as the specimen is an adequate amount, even liquid stool can be tested."
The nurse has finished installing a small-volume cleansing enema into a client. What instructions would the nurse give the client following the installation?
"Hold the solution in until the need to defecate is strong."
The nurse is caring for a client whose health care provider has written a prescription for "enemas until clear." Which explanation to the client about this procedure is correct?
"I will administer up to three enemas until there are no more pieces of stool in enema return."
The nurse needs to collect stool for occult blood testing from an 8-month-old client. The parent asks if the specimen for testing can be collected from the child's diaper. What is the best response by the nurse?
"Only if the stool has not been contaminated by urine."
The nurse caring for a client has just inserted a rectal suppository. What is the best instruction by the nurse at this time?
"Remain in horizontal position for 10 to 20 minutes."
The client asks to help express the small-volume enema solution. Which instructions by the nurse will best facilitate instilling the enema solution completely?
"Roll the bag toward the buttocks and then keep it rolled while removing it from the rectum."
What instruction would the nurse give the client before removing an indwelling urinary catheter?
"Take several slow, deep breaths."
The nurse has presented an educational inservice about caring for clients who have newly created ostomies. The nurse asks participants, "How will you know when a client begins to accept the altered body image?" Which responses by participants indicate a correct understanding of the material? Select all that apply.
"The client is willing to look at the stoma.", "The client expresses interest in learning self-care.", "The client makes neutral or positive statements about the ostomy."
A client has been prescribed a small-volume enema for constipation following surgery and asks the nurse how such a small amount of fluid can lead to a bowel movement. What is the nurse's best response?
"This enema pulls fluid from the intestine to stimulate defecation."
The nurse is preparing to administer an intermittent feeding to a client who has a nasogastric feeding tube. Place the following steps in the correct order. Use all options.
-Position the client with the head of bed elevated 30 to 45̊ degrees. -Verify correct tube placement. -Aspirate all gastric contents. -Verify that gastric residual volume is less than 200 mL. -Flush the tube with 30 mL water. -Administer the feeding.
When applying a condom catheter to a client, how much space would the nurse leave between the tip of the penis and the end of the condom?
1 to 2 in
The nurse is preparing to empty an open-ended colostomy pouch. Place in order the steps the nurse would take. Use all options.
1)Fold the end of the pouch upward like a cuff. 2)Empty the contents into a measuring device. 3)Wipe the lower 2 in (5 cm) of the pouch with toilet tissue. 4)Uncuff the edge of the pouch. 5)Apply the clamp.
The nurse is administering an intermittent tube feeding using a gravity set-up and open feeding bag system. At what level should the nurse place the feeding bag on the pole?
12 in (30 cm) above the stomach.
The nurse is preparing to administer a rectal suppository to an adult client. How many inches (or centimeters) should the nurse plan to insert the suppository?
3 inches (7.5 cm)
The nurse has finished aspirating the gastric contents before administering a prefilled, continuous tube feeding. At this point in the procedure, how much sterile water would the nurse use to flush the tube?
30 mL
The nurse is providing a continuous tube feeding for a client. At what angle should the head of the bed be set during the feeding?
30 to 45 degrees.
A nurse is testing stool for occult blood. The client wants to know how long it will take to know the results. The nurse tells the client that after applying the developer to the sample, the result will be read in how many minutes?
5 minutes
The client is to receive several medications via a gastric tube. How much water would the nurse flush the tube between the medications?
5 to 10 mL
The nurse is preparing to remove stool digitally for a client who is constipated. Which steps are included in this process? Select all that apply.
> Gently work the finger around and into the hardened mass to break it up and then remove pieces of it. > Generously lubricate index finger of dominant hand with water-soluble lubricant. > Instruct client to bear down, if possible, while extracting feces to ease in removal. > Insert gloved finger gently into anal canal, pointing toward the umbilicus.
Which procedures can be delegated to an unlicensed assistive personnel (UAP)? Select all that apply.
> administration of enemas until clear b) administration of small-volume enema d) application of a fecal incontinence device e) administration of a large-volume enema
The nurse is administering a large-volume enema to treat a client's constipation. After checking the enema device for defects, what should the nurse do next?
Add the enema solution and any additives to the enema bag
Which nursing interventions may be used for a client with a fecal impaction prior to digital removal of stool? Select all that apply.
Administer oil and cleansing enemas., Adjust medications to reduce the chance of constipation., Ensure adequate hydration., Include 30 grams of fiber in the diet.
The nurse prepares to provide gastrostomy insertion site care. The gastrostomy tube was placed this week. The client reports pain at the site. Which action does the nurse take next?
Administer pain medication.
The nurse is caring for a client who had a percutaneous endoscopic gastrostomy tube inserted earlier in the day. The sutures are still in place. Which interventions should the nurse plan to perform? Select all that apply.
Administer prescribed analgesics, as needed. Gently clean around the insertion site using a cotton-tipped applicator dipped in sterile saline. Measure the length of exposed tube and compare it with the length documented after insertion. Avoid placing tension on the feeding tube.
The nurse is assisting a client with changing an ostomy appliance. What is the best method of ensuring that the client has understood the procedure and is able to perform it independently?
After performing the first appliance change, observe the client performing the next change.
The nurse provides the client with a gravity feeding via a gastrostomy tube. Which action is correct?
Allow the feeding to infuse slowly from the feeding bag.
The nurse is talking with a client whose colostomy pouch frequently comes loose and fall offs. Which interventions are appropriate suggestions? Select all that apply.
Apply a commercially available skin barrier before applying the ostomy pouch., Thoroughly cleanse the skin surrounding the stoma and allow it to dry completely before applying the ostomy pouch.
A nurse delivers a tray of food to an older client and sets it on the overbed table. The client shows no interest in the food, however. Which actions should the nurse take? Select all that apply.
Ask why the client does not want to eat anything on the tray. Assess the client for signs of depression. Consult a dietitian if the problem persists.
A nurse enters a client's room to perform a tube feeding. Which nursing action should be performed first?
Aspirate stomach contents and check pH.
Prior to allowing a client to eat, which action is most important for the nurse to take?
Assess the client's level of consciousness
When preparing to administer a second dose of a prescribed vaginal suppository, the client reports discomfort in the vaginal area. What should the nurse do next?
Assess the vaginal area.
The nurse is preparing to collect a urine specimen from a client's indwelling urinary catheter. Which technique should the nurse plan to use?
Attach a sterile syringe to the luer-lock sampling port on the catheter drainage tubing and withdraw urine.
The nurse is collecting supplies to change the ostomy appliance of a client who has an ileostomy following surgery for a tumor. What items would the nurse prepare to wash around the stoma?
Basin of warm water
The nurse is administering a glucose test on a client and has lanceted the finger. Where should the nurse instruct the client to keep his or her hand?
Below the level of the heart.
The nurse is collecting a urine sample from an indwelling urinary catheter. Prior to cleaning the aspiration port, what would be the appropriate nursing action?
Bend the drainage tubing back on itself distal to the port.
The nurse is administering a large-volume cleansing enema. After stopping the enema, which instructions should the nurse provide if the client reports severe pain and bloating?
Breathe out in short, panting breaths.
The nurse is monitoring a client with a colostomy and notices that the ostomy appliance is leaking. What would be the appropriate nursing action in this situation?
Change the appliance immediately.
The nurse is required to give a prescribed medication via a gastric tube. The medication is available in tablet form. What should the nurse do first?
Check the drug administration guide to see if the medication can be crushed.
The nurse is preparing to administer medications to a client with a gastric tube. What is the best way to determine which medications can be crushed?
Check the drug guide.
The client with dysphagia has a regular meal tray delivered at breakfast. Which is the best action for the nurse to take?
Check the medical record for the client's prescribed diet.
The nurse is administering an intermittent tube feeding using a gravity set-up and open feeding bag system. After checking tube placement, which action would the nurse take next?
Check the residual (the amount of feeding left in the stomach from the last feeding).
The nurse obtains a client's blood glucose level. Which action does the nurse include?
Check the test strips for an expiration date.
The health care provider prescribes digital removal of stool for a client with liver cirrhosis. The nurse notes that the client is on precautions for a low platelet count. What action does the nurse take?
Clarify the request with the health care provider.
The nurse is explaining the procedure for collecting a midstream urine specimen to a female client capable of performing the procedure without assistance. How should the nurse instruct the client to cleanse the perineal area prior to collecting the sample?
Clean each side of the urinary meatus then cleanse over it.
The nurse is observing a client learning to change the ostomy appliance. Which action by the client would require the nurse to intervene?
Client cuts the opening on the new bag 0.5 in (1.25 cm) larger than the stoma size.
The nurse is preparing a bedpan to use for a client post-abdominal surgery. What is the most important concept that the nurse should remember when assisting a client with a bedpan?
Client dignity.
The nurse is preparing to obtain a stool specimen for ova and parasites culture. Which actions are correct? Select all that apply.
Collect 15 to 30 mL of liquid stool. Include visible blood, mucus, or pus in the specimen. Obtain the sample immediately after the client has a bowel movement. Use a specimen container with preservatives.
When obtaining a urine specimen from an indwelling urinary catheter, the nurse places a label on the specimen container. How should the nurse check the information on the specimen label?
Compare it to the client identification band.
The nurse is changing a colostomy bag for a client and notices that there is minor bleeding coming from the stoma. What is the recommended action in this situation?
Continue the procedure, because this is a common finding during stoma care.
The nurse observes the unlicensed assistive personnel (UAP) administering a large-volume enema to an older adult client. Which action by the UAP would require the nurse to intervene?
Continuing administration while the client reports severe cramping and bloating.
A nurse is caring for a client who has been prescribed a clear liquid diet. Which liquid can be included in the client's diet?
Cranberry juice
Digital removal of stool is considered a last resort after other unsuccessful methods of bowel evacuation have been performed. Which is the correct rationale for this statement?
Digital removal of stool may cause parasympathetic stimulation.
The nurse obtains the client's blood glucose result. What does the nurse do next?
Discard the test strip.
Which nursing assessment takes priority when administering an enema to a client?
Dizziness
The nurse has finished collecting a urine specimen from the client's indwelling urinary catheter. What would the nurse do with the collected specimen to prepare it to be sent to the lab?
Empty the urine from the syringe into a specimen cup with a lid.
When monitoring a client with a condom catheter, the nurse finds that the catheter will not stay on the client. What would be the initial recommended step for this situation?
Ensure that the condom catheter is the right size.
A client with dysphagia prepares to eat dinner. How does the nurse best help this client?
Ensure the head of the bed is high-Fowler.
The nurse is administering an intermittent tube feeding to a client via gravity using an open feeding bag system. What step would the nurse perform when the feeding bag is empty?
Flush the feeding bag with 30 mL water.
After removing the closing clamp on a colostomy appliance, what would be the nurse's next step before emptying the appliance?
Fold the end of the pouch upward, like a cuff.
While changing the ostomy appliance of a client with a colostomy, the nurse finds significant bleeding from the area around the stoma. What would be the recommended nursing action after notifying the health care provider?
Gently pat the area dry and apply the new appliance when the skin is completely dry.
The nurse places a bedpan under the buttocks of a client and asks the client to roll back over on the bedpan. What would be another method of having the client assist with getting on a bedpan?
Have the client flex his or her knees and lift the buttocks onto the bedpan.
When selecting a finger on a client to use for a glucose test, which finding should the nurse look for?
Healthy looking, warm, and no swelling, cuts, or calluses.
What action is the priority for the nurse to ensure that a child can retain a retention enema for the prescribed amount of time?
Hold the child's buttocks together for 5 to 10 minutes if needed to encourage retention of the enema.
A nurse is preparing to administer an enema to a client. Reviewing the health history, however, the nurse realizes that the client often has a problem with sodium retention. The nurse should know that it would be a contraindication to administer which type of enema to this client?
Hypertonic
A client reports a burning sensation when urinating for the first time following the removal of an indwelling urinary catheter. In this situation, what would be the nurse's intervention?
Inform the client that this is normal for the first few voids.
When removing an indwelling urinary catheter from a client, the nurse prepares to deflate the catheter balloon. Which is the proper method for deflating the balloon?
Insert a syringe into the balloon inflation port and allow the water to come back by gravity.
The nurse is inserting an enema tube into the anus of the client to treat constipation. How should the nurse insert the tube?
Insert tube 3 to 4 in (7.5 to 10 cm) and angle toward the naval.
The nurse is preparing to administer medications to a client with a gastric tube. What equipment will the nurse gather to administer medications to the client? Select all that apply.
Irrigation set, Gloves, Waterproof pad, Tap water
What is the most important advantage of using a condom catheter versus an indwelling catheter?
Less potential for infection
The nurse encounters difficulty obtaining a large enough blood droplet for a capillary blood sample for glucose testing. Which action does the nurse take next?
Lower the hand below heart level and stroke the finger.
What action would the nurse perform when removing a bedpan following client use?
Lower the head of the bed slightly.
The nurse is caring for an adult client by inserting a rectal suppository. Which action would be most appropriate by the nurse?
Lubricate the suppository and gloved finger.
The nurse is getting ready to administer a large-volume cleansing enema to a client undergoing bowel surgery. Which action should the nurse take prior to the procedure?
Lubricate the tip of the rectal tube for easy insertion.
The nurse is applying a condom catheter to an older adult client who has become incontinent of urine following hip surgery. In what position would the nurse place the client when applying this device?
Lying flat
The nurse is preparing to obtain an adult client's capillary blood sample for glucose testing. Which action is appropriate?
Obtain the blood sample from the edges of the fingers rather than the center of the fingertip.
The client experiences leakage around the condom catheter. Which action does the nurse perform?
Obtain the correct supplies and replace it.
The nurse performs gastrostomy site care and notes drainage. What action does the nurse take?
Place a drain sponge under the external bumper.
When changing a client's ostomy appliance, the nurse finds that feces continue to flow from the stoma, making applying the new appliance difficult. What would be the recommended action when this occurs?
Place a piece of gauze over the stoma to absorb the drainage.
The charge nurse is observing a new nurse collect a stool sample to determine the presence of occult blood. Which action by the new nurse would require intervention by the charge nurse?
Placing two drops of developer directly onto the stool sample
The nurse is reviewing a client's laboratory work before administering a large-volume enema. Which laboratory result indicates that a nurse should confer with the health care provider before administering the enema?
Platelet count of 18,000/mm3
Prior to placing the bedpan under a client's buttocks, what would the nurse apply to the bedpan if a urine specimen is not needed?
Powder
The nurse is reviewing a urinalysis laboratory report of a client. The nurse notes there are nitrates and white blood cells present in the urine. Based on these results, what intervention(s) would be necessary? Select all that apply.
Prepare to obtain a urine culture. Notify the health care provider. Prepare to obtain a specimen by catheterization.
What is the most important intervention the nurse can perform to prevent skin breakdown for clients using a bedpan?
Provide skin and perineal care after bedpan use.
When removing an indwelling urinary catheter from a client, the nurse notices resistance while attempting to pull out the catheter. What would be the immediate intervention in this situation?
Reattach the syringe to the port, aspirate again, and reattempt catheter removal.
The nurse needs to collect a stool specimen for culture from a client. The client passed stool into the toilet instead of using the collection container. What is the next step for the nurse?
Reinstruct the client on use of collection container for next bowel movement.
The nurse needs to collect a stool specimen for culture from a client with a colostomy. What is the proper procedure for the nurse?
Remove the current bag, collect stool sample, and replace with new bag.
Which nursing instruction is the priority to give the client who is receiving a retention enema?
Retain the enema solution for at least 30 minutes or as indicated, per manufacturer's direction.
The nurse is caring for a client with a gastrointestinal bleed who has a nasogastric (NG) tube. After administering the medications via the NG tube, what would the nurse do next?
Shut off nasogastric tube for 30 minutes
When administering a rectal suppository, in which position would the nurse position the client?
Side-lying
Which should the nurse advise the client to do following successful administration of a tube feeding?
Sit up for 1 hour
The nurse is emptying an ostomy appliance for a client on bed rest. In what position would the nurse place the client for this procedure?
Sitting
Which situation would require the nurse to contact the health care provider when changing an ostomy appliance?
Stoma appears brown in color.
A nurse has received a prescription to obtain a specimen for an occult blood test in a client who is being assessed for colon cancer. Which type of sample should the nurse obtain from the client?
Stool
The nurse is administering a large-volume cleansing enema to a client who reports severe cramping and bloating in the abdominal area. What is the recommended nursing intervention based on this report?
Stop the flow and encourage the client to take deep breaths before restarting the enema.
A nurse is administering a small-volume enema to a client to relieve fecal impaction. After initiating this action, the client reports nausea and lightheadedness. The nurse also notes a decrease in the client's heart rate. What should the nurse do first?
Stop the procedure and monitor client's heart rate.
What instruction will the nurse include in discharge teaching for a client who is prescribed a vaginal suppository?
Store this medication in its original container in the refrigerator.
A nurse is assisting a client with the use of a bedpan. The nurse understands that which statement about bedpans is true?
The largest part of a regular bedpan should be placed under the client's buttocks
The charge nurse is observing a new nurse care for a client who is receiving a continuous feeding through a nasogastric feeding tube. Which action by the new nurse would require intervention by the charge nurse?
The new nurse places the client in the left lateral recumbent position.
The nurse has placed a urine collection bag on an infant. How often should the nurse check the bag to see if the infant has voided?
The nurse has placed a urine collection bag on an infant. How often should the nurse check the bag to see if the infant has voided?
The nurse is assisting a client who is immobilized with a neck injury to use a bedpan for urinary elimination. What is one of the primary nursing goals when assisting a client with urinary elimination?
To promote comfort and normalcy with urinary elimination.
The nurse clamps the catheter drainage tubing to collect a urine specimen from a client's indwelling urinary catheter. How long can the nurse leave the tubing clamped to obtain a sufficient amount of urine?
Up to 30 minutes.
Which would be the best choice of a device for urinary elimination for a 42-year-old male client who is on bed rest following knee surgery?
Urinal
A nurse has just removed an indwelling catheter from a client. Which common complications of urinary function should the nurse monitor for in the client, after removal of an indwelling catheter? Select all that apply.
Urinary retention, Difficulty voiding, Burning or irritation while voiding
The nurse is teaching a client how to collect a midstream urine sample. After the client has cleaned the perineal area or penis, what instruction would the nurse give to the client?
Void a small amount of urine into the toilet, bedpan, or commode prior to collecting the sample.
When obtaining a urine specimen from an indwelling urinary catheter, how would the nurse clean the aspiration port?
With an alcohol wipe.
The nurse is caring for a female client who has used the bedside commode. What things should the nurse document for this client? Select all that apply.
characteristics of urine and/or stool, tolerance of activity, alterations in skin integrity
Which clients have contraindications to receiving an enema? Select all that apply.
client with severe abdominal pain, client who has just undergone colon surgery, client with bowel obstruction, client with bowel inflammation
The nurse is preparing a client to administer a small-volume cleansing enema. In what position would the nurse place the client for this procedure?
lying on the left side with the bed flat and the back of the client facing the nurse
Which client situation would necessitate the nurse stopping the administration of an enema?MCW
reports of severe cramping
The nurse places a frail older adult client on the bedpan. After the client has voided and the nurse has removed the bedpan, what assessment is necessary for the nurse to complete?
skin assessment of the buttocks and coccyx
The nurse is teaching a client how to empty an ostomy appliance. How often would the nurse recommend the appliance be emptied?
when bag is one-third to one-half full
The nurse is caring for a client who is unable to retain the retention enema for the prescribed amount of time. Place the nurse's steps in the appropriate order. Use all options.
1)Explain to client the importance of retaining the enema for the prescribed time period. 2)Place client on bedpan in supine position while receiving enema. 3)Elevate the head of the bed 30 degrees for the client's comfort. 4)Notify health care provider.
Place in order the steps the nurse should take if a client reports cramping and bloating during enema administration. Use all options.
1)Stop administration if the client reports severe cramping and bloating. 2)Encourage the client to take short, panting breaths until the cramping subsides. 3)Administer the enema slowly at a height less than 18 in (0.5 m) above the client. 4)Discontinue the procedure and notify health care provider if pain occurs.
The nurse is administering medications to a client via a gastric tube. After administering the last dose of medication, how much water should the nurse flush through the gastric tube?
30 to 60 mL
The nurse is educating a family of a client with a gastric tube about administering medications. What would be appropriate to include? Select all that apply.
> Enteric-coated tablets cannot be ground. > Tablets must be ground to a fine powder. > Delayed-response tablets cannot be ground. > All ground powder must be mixed with tap water.
The nurse cares for a client with a gastric tube in place. Which actions does the nurse perform? Select all that apply.
> Insert a large syringe to decompress the stomach when the client reports nausea. > Give liquid stool softener and crushed pain medication through the tube as needed. > Administer one can of nutritional formula every 4 hours as prescribed.
For which client would using powder on a bedpan be contraindicated?
A client scheduled for a urinalysis using the urine that will be collected.
For which clients would a fracture bedpan be the most comfortable choice for urinary elimination?
A thin, elderly female client with pneumonia
A nurse is assisting a client with the use of a urinal. The nurse recognizes that which statement about the use of a urinal is true?
Unless contraindicated, nurses should encourage clients to stand to use a urinal.
The nurse is applying a condom catheter to a client who is urinating frequently and unable to control his urination following surgery. Which accurately describes the correct procedure for this application?
Apply the condom sheath securely enough to prevent leakage, but not so tight as to restrict blood flow.
The nurse is preparing to administer an intermittent feeding to a client who has a feeding tube. The nurse is unable to aspirate gastric contents and realizes that the tube is clogged. Which action is correct?
Connect a syringe filled with warm water to the feeding tube and flush it out using gentle pressure.
When monitoring a client with a continuous tube feeding, how often should the nurse confirm placement of the tube?
Every 4 to 6 hours.
A nurse needs to administer an enema to a client to lubricate the stool and intestinal mucosa to make stool passage more comfortable. Which type of enema should the nurse administer?
Oil retention
The nurse is assisting the client with transfer to a bedside commode. After the client stands and pivots, what should the nurse instruct the client to do next?
Place hands on the armrests prior to sitting down.
The nurse has placed a urinal between the legs of a client and instructed him to place himself onto the urinal. After covering the client with the bed linens, what would be the nurse's next action?
Place the call bell and toilet paper next to the client and instruct him to call when he is finished.
The nurse has assisted the bedbound client to place the urinal between the legs. The nurse instructs the client to place the penis into the urinal. After covering the client with the bed linens, what would be the nurse's next action?
Place the call bell and toilet paper next to the client and instruct the client to call when finished urinating.
The nurse is disposing the contents of the client's urinal. What is the correct procedure for cleaning the urinal?
Put on clean gloves, rinse the urinal with water, and dry with paper towel.
The nurse is using a large syringe to administer an intermittent feeding to a client who has a nasogastric feeding tube. Which method should the nurse use to increase the flow rate of the formula?
Raise the height of the syringe.
In what position would the nurse place a female client who is using a bedpan?
Sitting upright.
The nurse is caring for a client who has dysphagia and is unable to eat independently. The nurse is preparing to assist the client in eating a meal. Which action is appropriate?
Speak to the client but limit the need for the client to respond verbally while chewing and swallowing.
Which client position will best aid the nurse in insertion of a vaginal cream?
Supine position with legs bent at the knees
The nurse is inserting a medication via a rectal suppository to a client. What would the nurse instruct the client to do?
Take slow, deep breaths.
The nurse is caring for a female client who has used a bedside commode. The client requires assistance with personal care after voiding. How should the nurse assist the client with personal hygiene?
Wipe using one stroke from the pubic area toward the anal area.
The nurse is educating a preoperative client about gastric tubes. The client asks, "Why do I need to have a gastric tube?" How should the nurse respond?
"To help you consume sufficient nutrition."
A nurse is giving instructions to a client on the proper method for providing a stool sample. Which should the nurse tell the client?
"Void first in the toilet and then catch the stool in a plastic receptacle."
The nurse has a prescription to test a female client's stool for occult blood. The client just finished her menstrual cycle. How long should the nurse wait before testing stool for occult blood for this client?
3 days
The client with a gastric tube is prescribed a delayed-release tablet. Which are appropriate actions for the nurse? Select all that apply.
> Check the drug guide > Call the health care provider for prescription > Hold the medication
The nurse is instructing a client in proper technique for collecting a midstream urine sample. The client reports having voided only a short while ago and is concerned there may not be a sufficient volume of urine. Which amount of urine would the nurse instruct the client is necessary for testing to be performed?
Approximately 1.5 tablespoons (10 to 20 mL)
When administering a continuous tube feeding using a feeding pump and closed tube feeding system, the nurse plans to check for residual at which frequency?
Every 4 to 6 hours.
The nurse receives a prescription to remove an indwelling urinary catheter from a client who is pregnant and on bed rest. The nurse should be sure to maintain which safety protocol when performing this procedure?
Clean technique.
The nurse is teaching a client about emptying an ostomy appliance. How would the nurse instruct the client to hold the appliance when removing the closing clamp?
Upward
The nurse would like to minimize the time between appliance removal and replacement in the future. What is the best way to reduce time between appliance removal and replacement?
Use the measurements from the current appliance to mark the opening for future appliance changes.
The nurse is positioning a client for the removal of an indwelling urinary catheter. Where should the nurse stand during the procedure?
On the client's left side, if left handed.
The nurse has taught a client how to change the ostomy bag. How would the clamp be placed to demonstrate that the client understood the directions?
The curve of the clamp would follow the curve of the client's body.
When collecting a urine sample from the port of the client's catheter drainage tubing, the nurse inserts the syringe into the aspiration port, slowly aspirates enough urine for the specimen, and removes the syringe. What would be the nurse's next step?
Unclamp the drainage tubing.
