Skills Exam #5

True or false The stoma of a fresh ostomy should not be swollen. If it is the nurse should contact the HCP.

False

A patient comes into the clinic complaining of a wound on their elbow they have had for a couple weeks. The nurse takes a look at the wound and notices some unhealthy granulation tissue. Which of these would best describe what the nurse most likely saw? a. dark red and painful tissue b. bright red and painless tissue c. slough and escar d. scant amount of exudate

a

Following removal of a urinary catheter, the nurse should complete a bladder scan within __ to ___hours if the patient is unable to void post removal. a. 4 to 6 b. 6 to 8 c. 8 to 10 d. 2 to 4

a

Hematoma, Infection, and Dehiscence are all _______________ of wounds a. complications b. expected results c. adverse results d. none of the above

a

Which of these are unexpected findings when assessing an IV? a. Coolness b. IV fluids flow freely c. Tenderness d. Pain with flushing e. No heat

a,c

________________________ and _________________________ should be performed prior to the nasal and tracheal procedures to avoid the most common hazards of suctioning (hypoxemia, arrhythmias, and atelectasis). a. hyperventilation b. preoxygenation c. hypoventilation d. hyperoxygenation

a,d

How would the nurse prepare IV piggyback medication for admin to a client with an established IV? Select all that apply a. Wear gloves when assessing the site b. Flush the IV with 2 mL of saline c. Place the piggyback bag lower than the primary bag d. Use sterile technique when preparing the medication e. Establish flow rate for infusion

a,d,e

When suctioning a client with a tracheostomy, which nursing intervention is correct? a. Hyperventilate the client with room air before suctioning b. Apply suction only as the catheter is being withdrawn c. Insert catheter until the cough reflex is stimulated d. Remove inner cannula prior to suctioning

b

Which of these is an unexpected finding with an urostomy? a. mucus in the urine b. blood in the urine c. clear yellow urine d. straw colored urine

b

Which finding would let the nurse know that airway suctioning is required? One or more can be correct a. The patient has been coughing sporadically b. The nurse hears diminished breath sounds in the bases c. The patient is restless and reports shortness of breath d. The nurse sees visible excess sputum in the airway e. The patient is complaining of oral pain and the nurse notes some angioedema

b,c,d

When performing a wound culture, avoid which of the following (select all that apply). a. cleanest area b. pus c. slough d. necrotic tissue e. eschar

b,c,d,e

You are monitoring Ms Jones for signs of CAUTI. Which of the following signs may be indicative of a catheter associated urinary tract infection? (Select all that apply) a. Nausea b. Chills c. Abdominal Pain d. Confusion e. Loss of appetite f. Fever

b,d,f

A client has had his catheter removed. Which finding would indicate the need for a new one? a. anuria b. polyuria c. retention d. incontinence

c

When opening a sterile field which flap would you open first? a. the flap closest to you b. the side flaps c. the flap farthest from you d. flap towards patients feet

c

Which condition would the nurse question using the negative pressure wound vac with? a. chronic ulcer b. upper thigh wound c. hip wound with slight bleeding d. treated osteomyelitis within the vicinity of the wound

c

Which food or drink would the nurse instruct a client with a new colostomy to avoid because it produces large amounts of gas? a. coffee b. milk c. cabbage d. cheese

c

Which instruction would the nurse give to a client having a residual urine test? a. Attempt to void when the catheter is in place b. Collect a specimen of urine midstream c. Empty the bladder before the catheter is inserted d. Void right after the urinary catheter is removed

c

Within how many hours would you expect a surgical patient to void? a. 6 hours b. 4 hours c. 8 hours d. 12 hours

c

A client underwent surgery and developed a wound without tissue loss. While caring for the client, the nurse detects abscess formation. Which assessments made by the nurse support the observation? Select all that apply a. Necrosis of skin edges b. Swelling of the incision cite c. Purulent drainage d. Erythema of the incision line more than 1 cm e. Localized fluctuance beneath the wound when palpated

c,e

A catheter is specifically designed to maneuver around obstructions or blockages in the urethra such as with enlarged prostate glands in males a. straight b. foley c. condom catheter d. coude

d

An infant returns to the pediatric unit with an IV after corrective surgery. What is the priority nursing action? a. Apply adequate restraints b. Remove the NG tube c. Administer a mild sedative d. Assess IV for infiltration

d

How would the nurse describe the exudate characteristic of a serosanguineous wound? a. Beige pus with fishy odor b. Greenish-blue pus c. Creamy yellow exudate d. Blood-tinged amber fluid

d

Many patients empty their urostomy bag every two to four hours or when the pouch becomes _______________ full. a. one half b. totally full c. one fourth d. one third

d

The nurse knows that an ileostomy is an ostomy in the ________________________ a. large intestine b. ascending colon c. descending colon d. small intestine

d

The nurse measures the stoma with a template and then cuts and fits the ostomy barrier to a size that is _________________ than the stoma. a. 0.5mm smaller b. 1mm smaller c. 4mm larger d. 2 mm larger

d

The respiratory status of a patient with Gullian-Barre syndrome progressively deteriorates, and a tracheostomy is performed. NG tubes are ordered. How would the nurse manage the tracheostomy cuff? a. Deflate the cuff before each feeding b. Inflate the cuff 1 hour before and 1 hour after c. Deflate the cuff after the tube feeding is complete d. Inflate the cuff before the feeding and 30 minutes after each feeding

d

When inserting a catheter what should you do after you see urine in the tube? a. stop and inflate the balloon b. pull the catheter back 1 inch and inflate the balloon c. advance the catheter 3 more inches and then inflate the balloon d. advance the catheter 2 more inches and then inflate the balloon

d

Should the piggyback bag be higher or lower than the primary bag?

higher

True or false Following removal of a urinary catheter, the patient may complain of mild burning with first void.

true

Describe purulent exudate using the drop down.* 1. thick and opaque 2. contains serous drainage with small amounts of blood present 3. clear, thin, watery plasma 4. fresh bleeding

1

Select the items that should be at a tracheostomy patient's bedside at all times a. Suctioning equipment b. Obturator c. Spare Trach kit d. Bag valve mask e. Crash cart f. Intubation kit

a,b,c,d

Describe serosanguineous exudate using the drop down.* 1. thick and opaque 2. contains serous drainage with small amounts of blood present 3. clear, thin, watery plasma 4. fresh bleeding

2

The patient's IV site is cool to the touch and swollen. The patient states "it hurts a little." List in order the steps the nurse should take. 1. Discontinue the IV 2. Stop the IV infusion 3. Elevate the affected site 4. Document the findings

2134

Describe serous exudate using the drop down. 1. thick and opaque 2. contains serous drainage with small amounts of blood present 3. clear, thin, watery plasma 4. fresh bleeding

3

Match the term to the definition a. Yankauer b. Outer Cannula c. Inner Cannula d. Tracheostomy e. Oropharyngeal suctioning 1. Opening that was created surgically that goes from the neck to trachea 2. Cannula that is removed by the nurse to dispose of or clean 3. Device that is rigid to suction secretion's from the mouth 4. Suction secretion's via the mouth using a Yankauer 5. Cannula placed by the doctor through the tracheostomy hole that stays in place

A3, B2, C5, D1, E4

Match the dressing to the wound type it would treat. 1. Foam 2. Transparent films 3. Hydrogels 4. Petroleum impregnated gauze 5. Alginates 6. Silicone based dressings a. Skin tear b. Dry wounds c. Pressure injury d. Painful wounds e. Wet wounds f. Venous ulcers

A4, B2, C6, D3, E5, F1

How long can an ostomy appliance be left for?

4-7 days

Just enough IV fluids running to keep vein open is called what? a. MARSI b. KVO c. Primary fluids d. Secondary fluids

b

The discharge, output from a stoma is called _____________ a. exudate b. purulent c. effluent d. drainage

c

Which is the recommended catheter size for a 3 year old? a. 5-6 Fr b. 15-16 Fr c. 10-12 Fr d. 8-10 Fr

d

How would the nurse classify a wound that exhibits some soft necrotic tissue with a semiliquid slough and exudate? a. yellow b. black c. red d. green

a

The nurse is caring for a client after surgical creation of an ostomy. The nurse observes the stool is formed. The stool in this consistency in which part of the colon? a. ascending b. descending c. ileum d. transverse

b

In which situations would you contact the provider? Select all that apply a. Moist, beefy red stoma b. Purple, dry stoma c. Peristomal irritated and open d. Peristomal skin intact e. Malodorous discharge

b,e

The nurse is caring for a female patient who is experiencing inadequate bladder emptying. The nurse obtains an order to determine post-void residual. Which catheter type would the nurse use to evaluate post-void residual? a. Coude catheter b. Indwelling catheter c. Straight catheter d. Foley catheter

c

What is the importance of preoxygenation? a. To prevent hyperventilation b. To increase the chance of hypoxemia c. To prevent hypoxemia d. To increase oxygenation

c

A two-piece set consists of an ostomy barrier (also called a ___________) and a pouch.

wafer

What are factors that can affect ones ability for their wounds to heal (Select one, some, or all that apply)? a. nutrition b. mobility c. stress d. diabetes e. age f. obesity g. medications h. alcohol use i. smoking

ALL

Which complication would the nurse monitor for in a patient who has been bed bound for 3 days? a. Hypotension b. Atelectasis c. Constipation d. Urinary tract infection e. Pressure injuries

ALL

The nurse is suctioning a patient's tracheostomy. What is the correct order of steps? 1. Don sterile gloves 2. Auscultate lungs and evaluate heart rate 3. Hyperoxygenate with 100% oxygen 4. Guide the catheter into the tracheostomy tube using sterile gloved hand 5. Prepare by turning suction on to between 80 - 120 mmHg pressure

25314

Describe sanguineous exudate using the drop down. 1. thick and opaque 2. contains serous drainage with small amounts of blood present 3. clear, thin, watery plasma 4. fresh bleeding

4

Match the IV part to the definition a. Access ports b. Roller clamp c. Sterile spike d. Drip chamber e. Backcheck valve 1. This prevents fluid or medication from travelling up into the primary IV bag 2. This allows air to rise out from a fluid so that it is not passed onto the patient. It is also used to calculate the rate at which fluid is administered by gravity (drops per minute). It should be kept ¼ to ½ full of solution. 3. This is used to regulate the speed, or stop, an infusion by gravity. 4. These are used to infuse secondary medications and to administer IV push medications. Can also be referred to "Y ports" 5. This part of the tubing must be kept sterile as you spike the IV bag

A4, B3, C5, D2, E1

Phlebitis is inflammation of the ________ a. vein b. artery c. dermal layer d. subcutaneous layer

a

The RN delegates a task to an LPN who is caring for a patient with a tracheostomy. Which task can the LPN perform? a. Provide trach care using sterile technique b. Develop a plan to avoid aspiration c. Assess client's condition after tracheostomy d. Teach the client about tracheostomy care

a

The nurse is caring for a client who had major abdominal surgery a day ago. Which factor increases the risk of them developing abdominal wound dehiscence? a. BMI of 35 b. Placement of T-tube c. Receiving beta blockers d. Presence of excessive flatus

a

The nurse is providing patient education on the care of an ostomy. Which of the following statements by the patient would indicate that further education is necessary? a. "I should plan to replace the pouch system every 8-10 days." b. "Wafer should be cut 1/16 to 1/8 an inch larger than the stoma." c. "It is important to chew all foods completely and slowly." d. "I will keep a diary of the foods I eat and my stool pattern."

a

What action will the nurse take first when a clients IV rate is too slow? a. Evaluate the appearance of the catheter insertion site b. Reposition client's arm c. Determine the amount of fluid that needs to be administered d. Adjust flow clamp to correct rate

a

What is 0.45% saline indicated to treat? What type of solution is it? a. diabetic ketoacidosis; hypotonic b. fluid and electrolyte replacement; isotonic c. hyponatremia; hypertonic d. avoid pulmonary edema; hypotonic

a

Which action by the nurse best facilitates communication for a patient who just had a partial laryngectomy and tracheostomy? a. Provide means for the client to write b. Allow time to lip read what the client says c. Deflate the tracheostomy cuff to allow verbalization d. Remind the patient that speech is still possible after a laryngectomy

a

Which intervention is most important in preventing hospital acquired CAUTIS? a. Removing the catheter b. Washing hands with soap and water before and after assessing the catheter c. Cleansing the urinary meatus with soap and water twice a day d. Keep drainage bag off the floor

a

Which intervention would the nurse do before formulating a teaching plan for a child who is to undergo ostomy surgery? a. Assess the child's developmental status b. Determine the family's comprehension of the procedure c. Provide a list of resources to the family d. Collaborate with the school to ensure a smooth return for the child

a

Which of the following is NOT appropriate management of an indwelling urinary catheter? a. Allow the collection to rest dependently on the floor b. Keep the drainage bag below the level of the patient's bladder. c. Secure the catheter after insertion to the patient's leg with a leg strap d. Monitor the catheter for kinks

a

Which pressure range is appropriate for an infant? a. 80-100 b. 60-80 c. 100-120 d. 100-150

a

Which type of debridement would the HCP order for a client who needs removal of large amounts of nonviable tissue quickly? a. Surgical debridement b. Autolytic debridement c. Enzymatic debridement d. Mechanical debridement

a

After removing the catheter the nurse should instruct the patient to do what? One or more may be correct a. Drink oral fluids b. Call when they need to void c. Note color of the urine d. Note the time of first void

a,b rationale c - the nurse will note this patient does not need to d - nurse will note this the patient does not have to

An older adult in acute care has a risk of skin breakdown. Which intervention(s) are beneficial to the client? a. Avoiding pressure with proper positioning b. Reducing shear and friction sources c. Using support bases at all times d. Providing thorough skin care e. Providing beverages and snacks often

a,b,d

Which assessment findings indicate an older client is a risk for developing an infection? Select any that apply a. Weak cough b. Thin skin c. Decreased or absent leg hair d. Sluggish bowel sounds e. Indwelling urinary catheter f. Male pattern baldness

a,b,d,e

Identify the data pertinent to collect during a wound assessment (Select one, some, or all that apply). a. Anatomic location b. Type of wound c. Skin appearance proximal to site d. Appearance of wound bed e. Size of wound f. Pain g. Drainage noted h. Bowel Sounds i. Tissue damage

a,b,d,e,f,g,i

Which of these characteristics describes a stoma that should be reported to the HCP? a. bluish b. pale c. beefy d. swollen e. moist f. dry g. purplish h. black

a,b,d,f,g,h

When teaching a client with a new colostomy about appliance care and maintenance, which information will the nurse include? Select all that apply a. Change the ostomy pouch on a routine b. Replace ostomy wafer weekly or as needed c. Remove pouch when showering d. Empty ostomy pouch when 3/4 full e. Empty ostomy ouch before exercise and bedtime.

a,b,e

Before preparing your sterile field for the insertion of a Foley catheter. What would the nurse assess for? Which of these questions would be most appropriate? a. Any history of catheterization? b. Do you experience burning with urination? c. Do you have any joint limitations? d. Do you have allergies to iodine or latex? e. Have you had any previous gynecological procedures?

a,c,d,e

Which statement in correct regarding negative pressure wound therapy? Select all that apply a. A suction pump is used b. Necrotizing infections are treated c. Oxygen is administered under high pressure d. A low voltage current is applied to the area e. Chronic ulcers are reduced by removing fluids from the wound

a,e

A client with cancer of the prostate requests the urinal frequently but either doesn't void or voids very little. What factor is the likely cause? a. dysuria b. retention c. edema d. hematuria

b

A patient is scheduled to receive 0.9% normal saline at 0900. The nurse knows that this solution is classified as what? a. Hypertonic b. Isotonic c. Hypotonic d. Lactated ringers

b

According to the Centers for Disease Control and Prevention (CDC) which of the following is NOT an appropriate indication for insertion of an indwelling urinary catheter? a. End of life care b. Frequent urination c. Hourly monitoring d. Bladder obstruction

b

For which purpose would the nurse apply hypoallergenic tape of Montgomery straps in postoperative skin care? a. Improving perfusion to the wound to promote healing b. Protecting the fragile skin of the older client c. Increasing oxygenation to promote wound healing d. Conserving the client's energy

b

The nurse assess the client's incision site after bariatric surgery for signs of dehiscence. Which clinical finding supports the nurses conclusion that the client is experiencing wound dehiscence? a. Loosening of the sutures b. Sharp increase is serosanguineous drainage c. Purplish color of the incision d. Protrusion of abdominal organs

b

When performing nasal suctioning, have the patient lean their head ____________________ to open the airway. This helps guide the catheter toward the trachea rather than the esophagus. a. forwards b. backwards c. to the right side d. to the left side

b

Which assessment finding would the nurse alert the HCP of right away? a. Red beefy looking stoma b. Blanching, dark red to purple colored stoma c. Small amount of bleeding d. Excessive gas

b

Which dressing should be avoided with infected wounds? a. hydrogels b. hydrocolloids c. silicone based d. foam

b

Which mechanism of action for wet to damp saline moistened gauze for wound debridement is correct? a. Promoting dilution of viscous exudate b. Removing the necrotic tissue mechanically c. Causing a breakdown of the denatured protein of the eschar d. Promoting the spontaneous separation of necrotic tissue

b

Which member of the health care team is considered the primary person to insert an indwelling urinary catheter to a client who underwent a hysterectomy? a. CNA b. LPN c. RN d. Doc

b

Which nursing action is appropriate when suctioning the secretions of a client with a tracheostomy? a. Use new sterile catheters each time b. Initiate suction as catheter is being withdrawn c. Insert the catheter until the cough reflex is stimulated d. Remove the inner cannula before inserting the suction catheter

b

Which nursing intervention is the priority for the nurse when preparing to administer an IV piggyback med to a client who is receiving a continuous infusion of IV fluids? a. Get an additional IV pump for the medication b. Check the compatibility of the medication against the continuous IV solution c. Disconnect the continuous IV solution to run the piggyback medication d. Flush the client's IV to ensure patency

b

Which dressings would the nurse review as beneficial for the recovery of a client's red colored wound that was caused by pressure? Select all that apply a. Absorptive dressings b. Hydrocolloid dressings c. Transparent dressings d. Moist gauze dressings with antibiotics e. Non-adhering dressings with ointment

b,c,e

Which actions would be included when doing tracheostomy care? select all that apply a. Suction the client before starting tracheostomy care b. Use sterile technique when cleaning the inner cannula c. Use sterile tipped cotton swabs to clean the inner cannula d. Don sterile gloves before removing the inner cannula e. Use hydrogen peroxide to clean the inner cannula

b,d

The nurse has successfully taken the plastic coating off the catheter and dipped the catheter into the lubricant. The nurse has now moved her sterile field to the bed between the patients legs. Which task would the nurse complete next? a. Clean the vaginal area with 3 iodine cotton balls b. Use non-dominant hand to spread the labia minora and inspect the urethra c. Inform the patient you are going to clean their vaginal area and it will be cold d. Verbalize your non-dominant hand is now unsterile

c

The nurse is caring for a client with a tracheostomy. Which action would the nurse implement when performing trach suctioning? a. Ensure that the cuff of the tracheostomy is inflated during suctioning b. Loosen the clients secretion's before suctioning by instilling saline c. Preoxygenate the client before suctioning d. Employ gentle suctioning as the catheter is being inserted

c

The nurse is caring for a patient who had a colostomy placed two days earlier. The nurse notes that the stoma is moist and beefy red. Which action should the nurse be expected to take based on these findings? a. Notify the physician of the findings immediately. b. Remove the bag and apply pressure to the stoma. c. Document the assessment findings of the stoma. d. Change the appliance pouch and clean the skin.

c

The nurse is performing a wound assessment and dressing change. After removing the outer dressing, the nurse discovers that the packing in the wound bed is dry and stuck. To prevent tissue destruction and pain, the nurse knows to perform which of the following? a. gently remove the dressing - it will debride the wound b. leave the dressing intact and recover it c. soak the packing with saline before removing it d. pull the packing out quickly to get it over with

c

The nurse is removing a Foley catheter. What needs to be noted before disposing of the catheter? a. amount of urine b. color of urine c. tip intact d. a and b e. a and c f. b and c

c

The nurse piggybacks an IV antibiotic solution into a primary IV line using gravity flow tubing. After completion of the infusion, the client expresses concern about air in the piggyback tubing. How will the nurse respond? a. Air in the tubing, even if it got into the vein, will not be fatal unless it is a large amount b. The antibiotic and now the air flowing into the primary IV bag, not into the venous system directly c. The solution from the large IV bag begins to flow when the solution from the small bag ceases to flow d. The clamps on the tube leading from both bags will be closed for a few minutes to prevent air from entering the vein

c

True or false Once the nurse has transferred the urine into the sterile urine cup. What is the NEXT action? a. Remove gloves and hand hygiene b. Label the urine cup c. Wash the cup with a germicidal wipe d. Place the syringe on the drape and clean up the garbage

c

When caring for a patient with a tracheostomy tube, a good rule of thumb is to clean the inner cannula every _______ to _______hours (at a minimum). a. 6 to 12 b. 1 to 2 c. 12 to 24 d. 4 to 6

c

Which action would the nurse take after observing dehiscence of the patient's abdominal wound with evisceration? a. Call for help b. Obtain vital signs c. Reinsert the organs using aseptic technique d. Cover the wound with a sterile towel moistened with sterile saline

d

Which client statement indicates understanding of content taught about removing his 3 way indwelling catheter and bladder irrigation? a. I will probably have dark red urine b. I will struggle to urinate c. I will probably have diluted urine d. I may experience burning when I pee

d

Which combo presents the highest risk for the development of pressure injuries? a. Periodic diaphoresis, occasional sliding down in bed b. Minimal reaction to painful stimuli, receives tube feedings c. Spending extensive time in chair, BMI of 23 d. Incontinence, inability to move independently

d

Which information to promote self management would the nurse include to a client being discharged with a new ileostomy? Select all that apply a. Consume 1500 mL/day b. Limit alcohol to 1-2 glasses per day c. Include plenty of nuts and seeds in your diet d. Change appliance every 4-7 days e. Empty pouch when 2/3 full

d

Which instruction would the nurse include in the teaching plan for a client who has a new colostomy and is learning how to care for the skin around the stoma? a. Cut an opening about 1/3 an inch larger than the stoma b. Avoid soap and irritating agents c. Consume dairy, buttermilk and yogurt d. Empty the pouch before it is 1/3 full

d

While caring for a client with a portable drainage system, the nurse observes that the collection container is half full. The nurse empties the container. Which nursing intervention would the nurse do next? a. Encircle the drainage on the dressing b. Irrigate the suction tube with sterile saline c. Clean the drainage port with an alcohol wipe d. Compress the container before closing the port

d

When drawing up a urine specimen from a newly placed catheter how much urine is needed? a. 10 mL b. 15 mL c. 20 mL d. All of the above

d - anywhere from 10-30 mL

True or false In emergent situations, a provider order is still required for airway suctioning.

false

Your patient with a tracheostomy puts on their call light. As you enter the room, the patient is coughing violently and turning red. Prioritize the action steps that you will take. 1. Assess lung sounds 2. Suction patient 3. Provide oxygen via the trach collar if warranted 4. Check pulse oximetry

4231

Which of these are signs/symptoms of an infection in the wound? a. Fever over 101 F b. Overall malaise c. Increased shortness of breath d. Increasing or continual pain in the wound e. Increased redness or swelling around the wound f. Loss of movement or function of the wounded area g. Change in level of consciousness and/or increased confusion

ALL but c

Pressure injuries are something that can be avoided if proper preventative measures are put in place. What tool is used to assist nurses in objectively measuring risk factors for development of pressure injuries?

Braden scale

Patients that have a stage 4 pressure injury are at risk for developing? Why?

Osteomyelitis. Potential bone exposed.

What are the 4 types of exudate?

Sanguineous Serous Serosanguineous Purulent

The nurse knows that this is the reason for priming the tubing.

To prevent air from going into the vein

___________________________ is a specific foam dressing used with suctioning to remove fluid and decrease air pressure around a wound to assist in healing. Worn 24 hours a day. Removes fluid from the wound while assisting in pulling the edges of the wound together

negative pressure wound therapy (wound VAC)