UWORLD FUNDAMENTALS part 3
Airborne precautions are for what 4 diseases?
SARS (Severe Acute Respiratory Syndrome), TB, Measles and Varicella
The nurse is caring for a client who is having a thoracentesis. Following the procedure the nurse monitors for complications. The initial postprocedure monitoring plan should include what? SATA 1. level of alertness 2. Lung sounds 3. Oxygen saturation 4. Respiratory pattern 5. Temperature 6. Urine output
1,2,3,4 Following thoracentesis, the nurse should monitor for signs of pneumothorax, including level of alertness, respiratory rate, respiratory effort, oxygen saturation, and lung sounds.
A hospitalized client is scheduled for a percutaneous kidney biopsy at 10 AM. The PN reviews the client's vital signs and most current serum laboratory results at 8 AM. Which client finding is most important to report to the registered nurse? 1. Blood pressure of 180/100 mm Hg 2. Creatinine of 2 mg/dL (177 umol/L) 3. Hemoglobin of 9.8 g/dL (98 g/L) 4. Platelet count of 120,000/mmm (120x10/:L)
1 Percutaneous kidney biopsy is an invasive diagnostic procedure, it involves inserting a needle through the skin to obtain a tissue sample that is then used to determine the cause of certain kidney diseases. The kidney is a highly vascular organ, therefore, uncontrolled hypertension is a contraindication for kidney biopsy as increased renal arterial pressure places the client at risk for post-procedure bleeding. Blood pressure must be lowered and well controlled (goal <140/90 mm Hg) using antihypertensive medications before performing a kidney biopsy.
The nurse cares for a confused client who continues to pull at the IV catheter on the left forearm despite frequent instructions not to do so. What is the nurse's next action? 1. apply a gauze wrap and elastic stockinette around the IV site 2. apply a mitt on the right hand 3. apply a soft wrist restraint on the right wrist 4. apply an arm board to the left arm
1 The least restrictive device or method to keep a client from interfering with medical treatment should always be tried first, before applying a physical restraint.
A nurse is caring for 4 clients. Which prescription by the health care provider would the nurse question and seek further clarification before administering? 1. 0.45% sodium chloride for a client with severe gastroenteritis who had 12 episodes of diarrhea and vomiting in the past 4 hours. 2. IV bolus of 1000 mL 0.9% sodium chloride solution for a client in anaphylaxis due to a food allergy. 3. IV bolus of 1000 mL 0.9% sodium chloride solution for a client with diabetic ketoacidosis who has a serum glucose level of 650 mg/dL 4. IV mannitol 25% solution for a client with a closed head injury who is exhibiting signs of increased intracranial pressure.
1 The nurse should questions the administration of a hypotonic IV solution (ie, 0.45% sodium chloride) to replace gastrointestinal tract fluid losses as this would create a concentration gradient and shift fluid out of the intravascular compartment into interstitial tissue and cells, worsening the client's fluid volume deficit.
The clinic nurse is reinforcing client teaching about the tiotropium that has been prescribed for chronic obstructive pulmonary disease (COPD). Which statement indicates that the client has a correct understanding of this medication? 1. A capsule holds the powdered medication that I put in a special inhaler. 2. I do not need to rinse my mouth with water after taking tiotropium. 3. I have been taking tiotropium every time I have difficulty breathing 4. Tiotropium helps control my COPD by reducing inflammation in my airway.
1 Tiotropium (Spiriva) is a long-acting, 24 hours, anticholinergic inhaled medication used to control chronic obstructive pulmonary disease (COPD) and is administered most commonly using a capsule-inhaler system called the HandiHaler. The powdered medication dose is contained in a capsule in the inhaler device and pushes a button on the side of the device, which pokes a hole in the capsule. AS the client inhales, the powder is dispersed through the hole.
The nurse is caring for a client who weight 450 lb (204.1 kg) 2 days after bariatric surgery. The client is pleasant, cooperative, and able to fully bear weight. What would be the most appropriate method for transferring this client safety? 1. 1-person safety standby with walker. 2. 2-person full-body sling lift 3. 2-perons standing-assist lift 4. 4 person full body sling lift
1 When determining the most appropriate method to transfer a client safety, the nurse should assess: 1. whether the client can bear weight. 2. whether the client is cooperative.
The nurse observes a student nurse administer a tuberculin skin test using the intradermal route. The nurse intervenes when the student performs which action? 1. Advances tip of needle through epidermis until the bevel is no longer visible under the skin. 2. Chooses a 1 mL tuberculin syringe with a 27 gauge 1/4 inch needle, dons clean gloves. 3. Injects medication slowly raising a small wheal (bleb) on the skin. 4. Inserts at a 10-degree angle almost parallel to skin with the bevel up.
1 Intradermal dermal injection delivers a small amount of medication (0.1 mL) into the dermal layer of the skin, just the epidermis. This parenteral route is used to perform allergy testing and TB screening.
The nurse is inserting an indwelling (Foley) urinary catheter into a male client. After inserting the catheter about 6 inches in (15.2 cm), the nurse notes drops of urine in the tubing. What action should the nurse take next? 1. Further inset the catheter 1-2 inches (2.5-5.1 cm) 2. Have the client hold his breath. 3. Immediately inflate the 5 mL balloon. 4. Secure the tubing to the client's leg.
1 Urine could be in the urethra and evident in the tubing even though the tip with the balloon is not in the bladder. It is necessary to further insert the catheter before inflating the balloon to make sure the tip is in the bladder and not the urethra (causing urethral trauma).
The nurse preceptor observes a graduate PN collecting a urine sample for urinalysis and culture as pictured in the exhibit. What is the preceptor's best action? 1. Advise the graduate nurse to discard the collected urine specimen and record the output. 2. Advise the graduate nurse to use a sterile specimen cup rather than a graduated container for collection. 3. Explain to the graduate nurse that midstream clean catch or straight catheterization is required. 4. Remind the graduated nurse that the specimen should be kept cool until it is sent to the laboratory.
1 Urine specimens are collected aseptically from the port located on the tubing of an indwelling urinary catheter, therefore, the client's collected urine should be measured and discarded. Colonization and multiplication of bacteria within the stagnant urine in the collection bag may occur and cause incorrect results.
The nurse is contributing to the plan of care for a client who has active varicella with open, moist lesions. Which of the following actions are appropriate to include in the plan of care? select all that apply 1. Don gown, gloves, and N95 respirator when entering the client's room. 2. Ensure that pregnant staff members are not assigned to care for this client' 3. Place single use, disposable thermometer and stethoscope in the room. 4. place the client in a private room with negative air pressure. 5. request discontinuation of isolation precautions once all lesions are dry and crusted
1, 2, 3, 4, 5 Airborne precautions indications, TB, Varicella, herpes, rubeola. components: N95 respirator or powered air-purifying respirator. Negative pressure isolation room with high efficiency particulate air filter. As needed if contact with body fluid is anticipated clean gloves, disposable gown, goggles/face shield.
The hospice nurse is providing end of life care to a client who is experiencing anorexia and cachexia. Which interventions are appropriate? Select all that apply 1. allow the client to refuse food if not feeling hungry. 2. ask if the client is experiencing any pain or nausea. 3. involve the client in meal planning and food selection. 4. Plan for loved ones to share mealtimes with the client. 5 provide oral care and after meals to alleviate dry mouth.
1, 2, 3, 4, 5 The goal of end-of-life care is comfort and quality of life. In many cases, clients may be more comfortable when they do not eat or drink. Anorexia is a common complication in clients who are dying and may be exacerbated by many factors (eg, medication, anxiety, underlying disease). The client should be allowed to refuse food and drink. However, the nurse can implement strategies to stimulate appetite or alleviate symptoms associated with anorexia, including.
The nurse prepares to administer medications to a client. Which of the following client data are acceptable for use as client identifiers? Select all that apply 1. Date of birth 2. First and last name 3. Health care provider 4, Medical record number 5. Room number
1, 2, 4 During medication administration, the nurse identifies "the right client using information that is permanent and unique to the client. Acceptable identifiers are first and last name, date of birth, and medical record number.
The student nurse verbalizes the procedure for obtaining a wound culture to the nurse preceptor. Which of the following statements by the student indicate a correct understanding? Select all that apply. 1. I will apply the prescribed bacitracin ointment after collecting the wound culture. 2. I will cleanse the wound by gently flushing it with normal saline. 3. I will obtain a sample of the drainage accumulated since the last dressing change. 4. I will perform hand hygiene and apply new gloves before obtaining the wound culture. 5. I will swab the wound from the outermost margin toward the center.
1, 2, 4 Wound cultures are used to identify microorganisms and select appropriate antibiotics. The nurse should assess and clean the wound, swab from the wound center toward the outer margin, and avoid contamination (eg, hand hygiene, not touching intact skin with swab) to prevent misidentification of microorganisms.
A postoperative client with obesity and diabetes mellitus has an abdominal wound and is at risk for poor wound healing. Which of the following interventions does the nurse anticipate to prevent wound dehiscence? Select all that apply 1. administer docusate sodium orally every day 2. assist in applying an abdominal binder 3. implement caloric restriction to promote weight loss 4, monitor blood glucose to maintain tight control 5. reinforce teaching to hug a pillow while coughing
1, 2, 4, 5 Dehiscence occurs when the edges of a surgical wound fail to approximate (ie, partial or total separation of the skin and tissue layers). Clients with conditions that impair circulation, tissue oxygenation, and wound healing (eg, diabetes, smoking, obesity, advanced age, malnutrition, infection) are at a higher risk. Mechanical stress on the wound (eg, straining to cough, vomit, or defecate) also increases the potential for dehiscence. Interventions to prevent dehiscence include:
The nurse is performing open endotracheal suctioning for a client with a tracheostomy tube. Which of the following actions by the nurse are appropriate? Select all that apply. 1. Administers 100% oxygen prior to suctioning the client 2. Applies suction while withdrawing the catheter from the airway. 3. Instills sterile normal saline into the tracheostomy prior to suctioning. 4. Limits suctioning to 20 seconds during each suction pass. 5. Uses sterile gloves and technique throughout the procedure.
1, 2, 5 Open endotracheal (ET) suctioning is a skill performed to remove pulmonary secretions and maintain airway patency in clients who are unable to clear secretions independently. ET suctioning is important to promote gas exchange and prevent alveolar collapse, but inappropriate technique increases the client's risk for complications (eg, pneumonia, hypoxemia) or tracheal injury
The charge nurse is planning assignments for the day. Which clients will require the nursing staff institute contact precautions? SATA 1. 38 year old with methicillin-resistant Staphylococcus aureus 2. 42 year old with Clostridium difficile diarrhea 3. 69 year old with pertussis infection 4. 72 year old with vancomycin resistant Enterococcus 5. 80 year old with influenza
1,2, 4 Clients with multidrug resistant organisms (MRSA< VRE), C. difficile diarrhea, and scabies require nursing staff to implement contact precautions.
The nurse is drawing blood from a client's peripheral vein for laboratory specimens. Which of the following are corrected nursing actions? Select all that apply 1. do not leave a tourniquet on more than 1 minute while looking for a vein 2. draw the specimen while the skin is still wet with the alcohol prep. 3. if pulsating red blood is noted, withdraw the needle and apply pressure for 5 minutes. 4 using a highly visible vein on the ventral side of the client's wrist 5. vigorously shake the specimen tube to mix obtained blood with anticoagulant solution.
1, 3 A tourniquet is applied 3-5 inches above the desired puncture site no longer than 1 minute when looking for a vein. If longer time is needed, release the tourniquet for at least 3 minutes before reapplying. Prolonged obstruction of blood flow by the tourniquet can change some test results.
The nurse is caring for a postoperative client who has D5W/0 45% normal saline with 10 mEq potassium chloride infusion through a peripheral IV catheter. What are appropriate reasons for the nurse change the site? 1. Area around the insertion site feels cool to the touch. 2. Client reports mild arm discomfort after the infusion is started. 3. Edema is observed on the dependent side of the involved arm. 4. Intraoperative peripheral IV catheter was placed in the left antecubital region. 5. Serious fluid is leaking from the site despite secure connections.
1, 3, 5 Peripheral IV (PIV) catheter sites should be changed no more frequently than every 72-96 hours unless signs of complications (eg, phlebitis, infiltration) develop. Signs of phlebitis include erythema, edema, warmth, pain, and a palpable venous cord. Coolness to touch may indicate infiltration. The nurse should monitor for infiltration under the involved limb, particularly in the elderly. Infiltrated fluid may leak into loose skin and accumulate in dependent areas with no obvious signs of infiltration at the PIV site. If a PIV site leaks fluid, the tubing and catheter connections should be assessed. If all connections are intact, possible problems include infiltration/extravasation, a thrombus at the catheter tip, or damage to the catheter: all of these issues require a site change.
A nurse is caring for a client who is meeting with the palliative care team. After the meeting, the client's family asks for clarification about palliative care. Which statements about palliative care are accurate? select all that apply 1. palliative care focuses on quality of life and can be provided at any time' 2. palliative care is only possible with a terminal diagnosis of <6 months 3. palliative care is provided by a multidisciplinary team 4. palliative care is another term for hospice care 5. Palliative care provides relief from symptoms associated with chronic illnesses
1, 3, 5 Palliative care focuses on quality of life and symptom management (eg, pain, dyspnea, fatigue, constipation, nausea, loss of appetite, difficulty sleeping, depression). It can be given concurrently with life-prolonging treatment in the setting of terminal disease. Palliative care is provided by a multidisciplinary care team with a focus on the client's and their families.
A client is brought to the emergency department with multiple trauma injuries. The nurse sees the client's Jehovah's Witness identification card. As part of providing culturally competent care, the nurse would anticipate the client accepting which of the following? Select all that apply 1. Epoetin alfa 2. Fresh frozen plasma 3. Homologous packed red blood cells 4. Normal saline 5. Platelet transfusion
1, 4 Jehovah's Witnesses believe that transfusion of blood and blood products is not acceptable. Acceptable blood products alternatives include non-blood volume expanders (eg, saline, lactated Ringer's, dextran, hetastarch) and albumin-free erythropoietin. Unacceptable treatments are transfusions of whole blood, red cells, white cells, platelets, and plasma.
Place the nursing actions for performing a renal system physical assessment in the correct order. All options must be used. 1. Advise client to empty the bladder completely. 2. Auscultate the renal arteries in right and left upper quadrants 3. Document the assessment of renal system function. 4. Observe skin and contour of abdomen and lower back. 5. Percuss and palpate both the right and left kidneys.
1, 4, 2, 5, 3 1. Advise client to empty the bladder completely. 4. Observe skin and contour of abdomen and lower back. 2. Auscultate the renal arteries in right and left upper quadrants 5. Percuss and palpate both the right and left kidneys. 3. Document the assessment of renal system function.
Which of these are correct nursing actions related to client positioning? Select all that apply 1. position client in high fowler's for a paracentesis related to end stage cirrhosis 2. position client on left side after liver biopsy 3. position client on side with head, back, and knees flexed after lumbar puncture 4. position client Trendelenburg on left side if air embolism is suspected 5. position client with arm raised above head for chest tube placement.
1, 4, 5 For medical procedures, the nurse should ensure that the client: Has an empty bladder and is in high Fowler's or a sitting position for paracentesis. Is Trendelenburg on the left side for suspected air embolism. Has the arm raised above the head on the affected side for chest tube insertion. Lies on the right side (for 2 hours) and then supine (12-14 hours) after liver biopsy. Is side lying with the head back and knees flexed for lumbar puncture
The nurse is caring for a client who develops Clostridium difficile colitis after multiple days of antibiotic therapy. Which infection control measures are appropriate to implement? Select all that apply 1. disinfect surfaces with diluted bleach solution 2. hand hygiene with alcohol based hand rub 3. wear a face mask 4. wear a protective gown 5. wear nonsterile gloves
1, 4, 5 C. difficile poses a unique hazard in health care settings. This infection of the colon may develop/spread through contact with the organism or after prolonged antibiotic therapy alters normal bowel flora, allowing for C difficile overgrowth.
Which situation would required the nurse to obtain a prescription for physical restraints? 1. Bell restraint used for a confused client who keeps trying to get out of bed 2. elbow restraints used temporarily for a toddler while drawing blood . 3. full padded side rails in the raised position for a client during a seizure 4 long leg immobilizer for a client with a fractured tibia 5. soft ankle restraint to prevent bleeding at the femoral site following a cardiac catheterization
1, 5 common physical restraint devices include limb (eg, ankle, wrist) and belt restraints. The client situation, rather than the device, determines whether it is classified as a restraint.
The PN is collaborating with the register nurse to admit a client who will receive general anesthesia in the same day surgery unit. The client has never had surgery before. Which question is most critical for the nurse to ask the client during preoperative assessment and health history taking? 1. Has any family member ever had a bad reaction to general anesthesia? 2. have you ever experienced low back pain? 3. Have you ever had an anaphylactic reaction to a bee sting? 4. have you ever received opioid pain medications?
1. Malignant hyperthermia (HM) is a rare but life threatening inherited muscle abnormality that is triggered by specific, inhaled anesthetic agents and succinylcholine (Anectine), a depolarizing muscle relaxant used to induce general anesthesia.
The nurse observes a client who is postoperative left total knee replacement use a cane. Which action by the client indicates an understanding of the correct technique when walking down the stairs? 1. Descends with the cane on the step first, followed by the left leg, and then the right leg. 2. Descends with the cane on the step first, followed by the right leg, and then the left leg. 3. Descends with the left leg on the step first, followed by the cane, and then the right leg. 4. Descends with the right leg on the step fist followed by the left leg, and then the cane.
1. When descending stairs, the client should: Lead with the cane. Bring the weaker leg down next (in this client, It is the left leg) Finally, step down with the stronger leg.
A school nurse observes a 3 year old begin to choke and turn blue eating lunch. What should the nurse's initial action? 1. Abdominal thrusts. 2 Back blows and chest thrusts 3. Blind sweep of the child's mouth. 4. Call 911 for an ambulance.
1. Heimlich maneuver on child and adult. Foreign body aspiration is an emergency that requires immediate intervention when witnessed or highly suspected. The primary rescue intervention for adults and children over age 1 is abdominal thrusts, known as the Heimlich maneuver. This maneuver entails apply upward thrusts with a fist to the upper abdomen just beneath the rib cage. The upward action causes the diaphragm to forcefully expel air out of the airway, carrying the foreign body out with it.
The nurse inserts a urinary catheter into a female client who has not voided for 6 hours. No urine is returned. What action should the nurse take next? 1. Leave the catheter in place and insert a new catheter higher up in the perineal area. 2. Leave the catheter in place for 30 minutes and then recheck. 3. Notify the prescribing HCP that there is an obstruction. 4. Remove the catheter and reinsert it at a position higher than the initial insertion.
1. Urine output be expected as this client has not voided for 6 hours (obligatory amount is at least 30 mL x 6=180 mL). The most common explanation is that the catheter was unintentionally inserted into the vagina. The nurse should leave that catheter as a landmark and insert a new sterile catheter into the urethra which is located above the vagina.
A client with ascites had 54oo mL of fluid removed during paracentesis. The CHP prescribed 8 g of albumin IV per 1000 mL of fluid removed. If the albumin is supplied as 25 g in 100 mL bottles, how many mL will the nurse administer? record your answer using on decimal place.
172.8 mL albumin Albumin may be given after paracentesis to prevent volume depletion in a client with cirrhotic as ascites. Using dimensional analysis, use the following steps to calculate the volume of albumin per dose in milliliters: Identify the prescribed, available, and required medication information.
The nurse is acting as a preceptor for a student nurse in the labor and delivery unit. Which action by the student would require correction by the nurse? 1. Removing gloves prior to removing isolation gown. 2. Using a nail brush to scrub underneath artificial nails. 3. Using alcohol based hand sanitizer instead of washing hands when entering and exiting client room. 4. Washing hands and not wearing gloves when preparing medications in the med room.
2 Nurses should not wear artificial nails in the clinical setting, especially in areas with high-risk clients
The nurse is assigned to care for a hospitalized confused client with an indwelling urinary catheter. On entering the client's room, the nurse notes the client pulling at the catheter and grimacing in pain. Blood is tricking from the client's meatus and the urine is the drainage bag is pink. Which action should the nurse take first? 1. Collect a urine specimen and send to the lab. 2. Deflate the balloon on the urinary catheter. 3. Remove the catheter by gently pulling form the urethra. 4. Use a sterile 4x4 pad to absorb the blood around the meatus.
2 Because sings of traumatic injury are present, the nurse should follow steps to remove the catheter before further complications such as obstruction occur.
A client started 24 hours urine collection test at 6:00 am. The UAP reports discarding a urine specimen of 250 mL at 10:00 am by mistake but adding all specimens to the collection container before and after that time. What action should the nurse take? 1. Add 250 mL to the total output after the 24 hour urine collection is completed tomorrow morning. 2. Discard urine and container, and restart the 24 hour urine collection tomorrow morning. 3. Discard urine and container, have client void, add urine to new container and then restart test. 3. Relabel the same collection container, and change the start time from 6:00 am to 10:00 am
2 It is common practice to start a 24 hour urine collection test at the time of the client's first voiding in the morning. If any urine is discarded by accident during the test period, the procedure must be restarted. All produced urine should be placed in the same container and kept cold (on ice).
Which client is at the greatest risk for development of hospital-acquired pressure injuries? 1. 25 year old client with quadriplegia, urosepsis, temperature of 101 F (38.3 C0,, and white blood cell count of 18, 000/mm (18.0x10/L) 2. 50 year old client with AIDS who is receiving norepinephrine infusion and has a weight loss of 20 lb (9.1 kg) in a month, prealbumin level <10 mg/dL (q00 mg/L), and mean arterial pressure of 50 mm Hg. 3. 80 year old client 2 days post hip replacement with dementia, 2 Jackson-Pratt drains, and hemoglobin level of 14 g/dL (140 g/L). 4. 87 year old client 2 days post open cholecystectomy.
2 Pressire injuries are areas of localized skin injury and underlying tissue caused by external pressure with or without friction and/or shrearing. These results from ischemia and hypozia of tissure following periods of prolonged pressure. Clients at greatest risk include older adults wiith limited movement and long bone (femur) or hip fractures, those with quadriplegia, and the critically ill. Clients with deficits in mobility and activity, incontinence, inadequate nutrition, chronic illness, renal failure, anemia, problems with oxygenation, edema, or infection are also at increased risk. The client with AIDS has 5 risk factors: chronic illness and immune deficiency disease, significant weight loss, prealbumin <16 mg/dL (<160 mg/dL), indicating inadequate nutrition and protein deficiency, hypotension (decreases perfusion pressure): and receiving norepinephrine (Levophed), a vasoconstrictor. These risks nutrition to the cells.
A client on hospice home care is taking sips of water but refusing food. Family member appear distressed and insist that the personal care worker "force feed" the client. What is the priority nursing action? 1. explain to the family that this is a normal physiological response to dying. 2. explore the family's thoughts and concerns about the client's refusal of food 3. Recommend a feeding tube 4. Tell the family that "force feeding" the client could cause the client to choke on the food.
2 When a terminally ill person refuses food, family members often become upset and frustrated in their roles of nurturers and caregivers; they may feel personally rejected. Refusal of food is associated with "giving up" and is a reminder that their loved one is dying. It is not uncommon for family members to believe that a client would get stronger by eating instead of refusing food.
The nurse is preparing a client for magnetic resonance cholangiopancreatography. Which statements by the client would require the nurse to obtain further assessment data> Select all that apply 1. I ate lunch about 4 or 5 hours ago 2. I got a rash the last time I had IV contrast 3. I had my last period 6 weeks ago 4. I have a hearing aid implanted in my ear 5. I smoked a cigarette about an hour ago.
2, 3, 4 Magnetic resonance cholangiopancreatography uses MRI to visualize the biliary and hepatic ductal system. Contraindications, including pregnancy, the presence of certain metal implants, and an allergy to gadolinium (ie, noniodine, contrast agent), should be assessed before the procedure.
A client with a nasogastric tube is prescribed intermittent bolus enteral feedings with routine gastric residual checks. Which of the following actions by the nurse are appropriate? Select all that apply 1. Discard aspirated gastric residual in a biohazard container. 2. Flush the nasogastric tube before and after administering the feeding. 3. Place the client in the semi-Fowler position. 4. Start the feeding after obtaining a gastric residual volume of 75 mL. 5. Start the feeding when the gastric residual has pH of 6.
2, 3, 4 When administering bolus enteral feedings, the nurse should elevate the head of the bed to 30-45 degrees (semi-Fowler position) and keep it elevated for 30-60 minutes afterwards to decrease aspiration risk. Many institutions require the nurse to hold feeding if the client must remain supine (eg, diagnostic test). Feeding tubes should be flushed before and after feedings to keep the tube patent. Gastric residual volumes (GRVs) are traditionally checked every 4 hours with continuous feeding or before each bolus feeding. Per facility policy, enteral feedings may be held for high GRV (eg, .500 mL) to reduce aspiration risk. Low GRV indicates that the client is tolerating feeding well.
The nurse is preparing to administer several medications through a client's feeding tube. None of the medications are extended release. Which of the following actions should the nurse implement? Select all that apply 1. combine all medications and administer together 2. Crush each medication separately before administration 3. Determine if the medications are available in liquid form 4. Flush the tube before and after medication administration 5. Mix medications with enteral feeding formula before administration
2, 3, 4 When using a feeding tube, medications should be crushed, dissolved, and administered separately to prevent interactions. Feeding tubes should be flushed before and after each medication is given. Liquid medications should be used if possible.
A client with a tracheostomy is alert and oriented and able to tolerate oral intake. Which action would be appropriate to reduce the clients risk of aspiration pneumonia? 1. Fully inflate the cuff before feeding. 2. Have the client sit in an upright position with the neck hyperextended. 3. Partially or fully deflate the cuff. 4. Provide a modified diet of pureed foods.
3 The risk of aspiration in a conscious, alert, and oriented client with a tracheostomy can be reduced by partially or fully deflating the tracheostomy cuff, having the client in a upright position, monitoring for a wet cough or voice quality, and monitoring vital signs.
The nurse is reinforcing education about ascending stairs using a modified 3 point gait to a client prescribed crutches after a left ankle sprain. Place the instructions for ascending the stairs in the correct order. All options must be used. 1. Advance the affected leg and crutches up the stair. 2. Assume the tripod position, then bear body weight on the crutches. 3. Place the unaffected leg onto the stair. 4. Transfer body weight to the unaffected leg and raise the body onto the stair.
2, 3, 4, 1 Clients prescribed crutches after a musculoskeletal injury must be educated on appropriate device use to facilitate independent ambulation, promote wound healing, and prevent reinjury. A common method used to climb stairs is the modified three point gait :'leading with the good leg'), which is used to prevent weight bearing on the injured leg. Nurses should instruct clients with crutches to use the following steps to ascend the stairs with the modified three-point gait.
A female client is admitted to the emergency department after a motor vehicle collision. The client is unresponsive and on a mechanical ventilator. Which actions should the nurse perform? Select all that apply 1. locate and remove any medication patches. 2. Locate possible medical alert band or necklace. 3. remove rings and jewelry and lock in a secure location 4, remove tampon and replace with menstrual pad 5 take out contacts if no presence of eye trauma
2, 3, 4, 5 The unconscious client requires a thorough head-to toe assessment on admission to assess for foreign objects, devices, or belongings that have potential for harm.
The PN is assisting the RN in creating a care plan for a client who is intubated, on mechanical ventilation, and receiving continuous enteral tube feeding via a small-bore nasogastric tube. Which interventions should be included to prevent aspiration in this client? Select all that apply. 1. Check gastric residual every 12 hours 2. Keep head of the beat at >30 degrees 3. Maintain endotracheal cuff pressure 4. monitor for abdominal distension every 4 hours 5. Use caution when administering sedatives
2, 3, 4, 5 Clients who are critically ill are at increased risk for aspiration of oropharyngeal secretions and gastric contents, particularly when they are receiving enteral feedings.
A nurse is caring for a client with blindness due to diabetic retinopathy. Which interventions should the nurse implement for this client? Select all that apply 1. Ask a family member about the client's preferences for room arrangement. 2. Offer the client and elbow to hold and walk a half-step ahead for guidance. 3. Say "goodbye" when leaving the room to help orient the client. 4. Speak slowly and slightly louder so the client can understand. 5. Use a clock-face pattern to explain food arrangement on the client's meal tray.
2, 3, 5 The nurse should create a therapeutic and safe environment for the client who is blind while fostering as much independence as possible. Nursing interventions include the following: Offer the client an elbow for guidance while walking slightly ahead and describing the environment. Announce room entry and exit to orient and avoid startling the client. Describe the location of items (eg, food, hygiene supplies) using a clock-face orientation so the client can find them easily. Instruct the client to use a cane with the dominant hand and to sweep areas in front from side to side for orientation. Orient the client to the room and maintain this orientation for safety.
A client is being discharged after having a coronary artery bypass grafting x 5. The client asks questions about the care of chest and leg incisions. Which instructions should the nurse reinforce? SATA 1. Report any itching, tingling, or numbness around your incisions. 2. Report any redness, swelling, warmth, or drainage from your incisions. 3. Soak incisions in the tub once a week, then clean with hydrogen peroxide and apply lotion
2, 4, 5 The nurse should instruct the client with chest and leg incisions from coronary artery bypass grafting to wash them daily with soap and water in the shower. In addition, the client must be instructed not to apply powders or lotions to the incisions, to report any redness, swelling, or drainage increase, and to wear an elastic compression hose on the legs.
The PN observes a student nurse administering ear drops to an elderly client to help loosen cerumen. The nurse intervenes when the student performs which action? 1. instills ear drops at room temperature. 2. Instills ear drops with dropper by occluding the ear canal. 3. Places a cotton ball loosely in the outermost auditory canal after instillation. 4. Pulls pinna up and back and instills drops.
2. Otic medication are used to treat infection, soften cerumen for later removal, and facilitate removal of an insect trapped in the ear canal. They are contraindicated in a client with a perforated eardrum.
A new graduate nurse is administering enoxaparin to a client. Which action indicates the need for further orientation by the nurse preceptor? 1. Discourages the client from rubbing the injection site 2. Ejects air bubble that is in the syringe prior to administration 3. Inserts needle and injects medication at a 90 degree angle 4. Selects an injection site on the left lateral side of the abdomen
2. Enoxaparin comes in a prefilled syringe from the manufacture. To ensure complete medication delivery, the air bubble should not be expelled prior to injection. The injection site should be on the right or left side of the abdomen at least 2 inches from the umbilicus. The needle should be inserted at a 90 degree angle into a pinched up area of tissue. To prevent excessive bruising, the nurse should discourage the client form rubbing the area around the injection site.
A nurse is assisting with the care of a newborn during circumcision. Which is an appropriate intervention? 1. Apply a snug-fitting diaper following the procedure. 2. Anticipate the use of clean technique during the circumcision. 3. Offer oral fluids during the procedure. 4. Wrap the newborn's upper body in a blanket restraint for the circumcision.
4 Application of a blanket restraint or the use of a special board prevent injury during circumcision. Swaddling and the use of non-nutritive sucking are nonpharmacologic approaches to manage pain during circumcision.
A client is experiencing an exacerbation of chronic lower back pain after working in the yard all weekend. The nurse should reinforce the primary importance of which nonpharmacologic intervention for acute muscle pain? 1. heating pad 2. positioning for comfort 3. rest from pain aggravating activities 4. stretching exercise
3 Acute exacerbation of chronic back pain is usually associated with inflammation triggered by (strenuous and/or repetitive) activities that stress the previously injured area. Interventions should be directed toward reducing inflammation.
The nurse is performing rounding on client's in restraints. Which situation would require immediate intervention by the nurse? 1. Client in a belt restraint in the semi-Fowler position. 2. Client in mitten restrain in the side lying position. 3. Client in soft wrist restraints in the supine position. 4. Client in vest restraint in the high-Fowler position.
3 Clients in any form of restraint should not be in the supine position as it may lead to aspiration, especially in clients with altered mental status. The supine position may also increase anxiety and agitation. Unless contraindicated, clients in restraints should be placed in the side-lying, semi-Fowler, or high-Fowler position to promote airway patency and allow the client to safety swallow or expectorate secretions or emesis.
A home health nurse is visiting a 72 year old client who had coronary artery bypass graft surgery 2 weeks ago. The client reports being forgetful and becoming teary easily. How should the nurse respond? 1. don't worry. You'll feel better in a few weeks 2. how well are you sleeping at night 3. these symptoms can be common after major surgery. It will take 4-6 weeks to completely heal and start to feel normal again 4. you may be experiencing depression. I'll call the health care provider and see if we can get a prescription for an antidepressant.
3 Clients who have undergone surgery (eg, coronary artery bypass graft) may experience some postoperative cognitive dysfunction (POCD). This may include memory impairment and problems with concentration, language comprehension, and social integration.
A nurse is reviewing the most recent laboratory results of a client on the telemetry floor. The client is currently asymptomatic, and the telemetry monitor indicates sinus rhythm. Which critical value is most likely due to laboratory error? 1. Blood urea nitrogen of 60 mg/dL. 2. Creatinine of 4.o mg/dL 3. Potassium of 7.0 mEq/L 4. Sodium of 155 mEq/L
3 High serum potassium levels could be due to hemolysis or clotting during the blood draw. If clinical assessment does not correlate with laboratory values, repeat testing is needed.
A nurse is caring for a 2 year old child diagnosed with nephrotic syndrome who is in diapers and has a red, edematous genitals. Which collection technique is appropriate for the nurse to obtain daily urine specimen for proteinuria testing with a urine dipstick? 1. Apply adhesive urine collection bag around the genital area and wait for the child to void. 2. Intermittently catheterize the child every morning to avoid contaminating the specimen. 3. Place cotton balls in a dry diaper, when wet, squeeze urine onto dipstick. 4. Place urine dipstick in the child's diaper overnight and check result in the morning.
3 Nephrotic syndrome is characterized by massive proteinuria and hypoalbuminemia, which results in severe edema most evident in the abdomen, face, and perineum. Daily dipstick urinalysis determines the presence and pattern of urine protein loss to monitor for exacerbations. To collect a nonsterile urine specimen from a child who is not toilet trained, the nurse can place several cotton balls in a dry diaper and later squeeze urine onto a dipstick. The diaper is checked frequently and the sample collected and tested within 30 minutes of urination for the most accurate result.
The orthopedic health care provider instructs a client with a fractured right femur, who has been non-weight bearing for the past 5 weeks, to progress to full weight bearing on the right leg. Which advanced crutch gait that most closely resembles normal waking should the nurse reinforce when teaching the client? 1. 2-point gait 2. 3-point gait 3. 4-point gait 4. 5-point gait
3 The 4 point gait is appropriate for a client with leg weakness who can bear partial or full weight with both legs. It is the easiest gait to use as resembles normal walking and provides the most stability with 3 points of support on the ground at all times.
A nurse is caring for a group of client on a medical surgical unit. Which client is most at risk for contracting a nosocomial infection? 1. 51 year old client who received a permanent pacemaker 48 hours ago. 2. 60 year old client who had a myocardial infraction 24 hours ago. 3. 74 year old client with stroke and an indwelling urinary catheter for 3 days. 4. 75 year old client with dementia and dehydration who is on IV fluids
3 The nurse should be aware of the risk for nosocomial infections in young children, elderly, and immunocompromised clients, especially those with long hospital stays, indwelling catheters, and surgical incisions.
An elderly client at the end of life is visited by family members. One begins to cry and asks the nurse, "will you please stay for a few minutes?" The nurse has other clients to care for as well. Which statement by the nurse is the most helpful? 1. I am busy right now but can stay for a few minutes. 2. I can call the clergy to come sit with you. 3. I can stay and sit with you if you would like. 4. I don't think I should interrupt your family time.
3 During the end-of-life process the client's family members may be frightened, sad, confused, or concerned, and may ask staff questions about belief systems or the death process Sometime clients or family ask staff questions about belief systems or the death process. Sometimes clients or family members simply want the nurse to sit with them and provide reassurance that their loved ones are worthy of time and attention. The most therapeutic response by the nurse is to sit with the client and/or family for at least a few minutes.
The nurse is reinforcing information about techniques to improve sleep habits with a client who experience frequent insomnia. Which statement by the client requires further teaching? 1. I will avoid naps later in the day. 2. I will keep the bedroom temperature cool. 3. I will read in bed before trying to go to sleep. 4. I will try to go to bed and wake up at the same time each day.
3 Sleeping hygiene refers to a group of practices that promote regular, restful sleep. The nurse should encourage clients who have trouble sleeping (insomnia) to maintain good sleep habits. A primary objective is reducing stimuli in the bedroom. Clients should be taught to avoid non-sleep related activities (eg, reading, television, working) other than sex in bed. Relaxed reading before bed is helpful for stimulating sleep but should occur in a different setting, not in bed.
The nurse is conducting a home visit to assess an elderly client with advanced heart failure who lives alone. When the nurse asks about sodium intake, the client becomes angry and says, "I'm so tired of people telling me what to do! I'm going to eat what I want, so leave me alone!" Which of the following is the most appropriate response by the nurse? 1. I can tell that you want me to go, so I will call in a few days to see how you are doing. 2. I know you are frustrated with losing control of your life. 3. It sounds like you are angry. Tell me what's bothering you. 4. Okay, I'll just check your blood pressure and then go.
3 The client exhibits anger, which is likely a sign of grief due to loss of control from illness. However, the source of the client's anger is not clear. Therefore, further assessment is now indicated to understand more about the client's feelings and perceptions. Verbalizing feelings may also help the client to move past anger toward acceptance of the loss.
A nurse is preparing to administer 2 continuous IV medications currently via a 20 gauge IV. What is the nurse's priority action? 1. Assess the condition of the IV site. 2. Check 2 client identifiers before administering medications. 3. Consult a medication guide for compatibility. 4. Wash hands prior to administering medications.
3 The priority when administering 2 IV medications concurrently is to determine drug compatibility. Incompatible drugs given through the same IV line will deteriorate or form a precipitate. This change is visualized through either a color change, a clouding of the solution, or the presence of particles. If 2 or more drugs are not compatible, the nurse may consider inserting a second IV or consulting the pharmacist and the HCP to determine the safest and most beneficial plan for the client.
The nurse has unlicensed assistive personnel caring for a client with an acute attack of Meniere disease. Which action by the UAP will require follow up by the nurse? 1. assist the client in ambulating to the bathroom 2. Dim the room lights 3. Place the bed in low position with all side rails up 4. Turn off the television
3. Meniere disease (endolymphatic hydrops) results from excess fluid accumulation in the inner ear. clients have episodic attacks of vertigo, tinnitus, hearing loss, and aural fullness. The vertigo can be sever and is associated with nausea and vomiting. Clients report feeling being pulled to the ground (drop attacks) Safety is a priority for the client experiencing an acute attack of Meniere disease. Fall precautions include placing the bed in low position, raising 2 or 3 side rails, and assisting the client with arising and ambulating.
Examination of the urinary system requires an abdominal assessment. Therefore, assessment techniques must be reordered to optimize the examination. The steps for an renal system assessment are: 1. Empty the bladder to avoid discomfort during percussion and palpation and to provide a clean catch sample (if prescribed) 2. Inspect the abdomen and lower back for color, contour, symmetry, distension, and movements (eg, visible peristalsis). Inspection is always done first during physical examination.
3. The nurse should auscultate immediately after inspection as percussion or palpation may increase bowel motility and interfere with sound transmission during auscultation. Listen for renal artery bruits in the right and left upper abdominal quadrants. 4. Percuss for kidney borders, costovertebral angle tenderness, and bladder distension. A dull percussion sound indicates solid structures or fluid filled cavities (eg, distended bladder). Palpate for bladder distension, masses, and tenderness. 5. Document all renal assessment findings immediately after the examination.
The nurse prepares to exit the room of a client on airborne and contact isolation precautions. Place the following nursing actions in the correct order. All options must be used. 1. discard the gown and gloves and perform hand hygiene 2. exit the negative pressure room and close the door 3. place the call light within the client's reach 4. remove the gown and gloves without contaminating hands 5. remove the N95 respirator mask and perform hand hygiene.
3. place the call light within the client's reach 4. remove the gown and gloves without contaminating hands 1. discard the gown and gloves and perform hand hygiene 2. exit the negative pressure room and close the door 5. remove the N95 respirator mask and perform hand hygiene.
Which client is most at risk for hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA)? 1. 15 year old student athlete in the emergency department with a fractured femur. 2. 46 year old with a large abdominal incision and 2 peripheral IV lines. 3. 72 year old who received a permanent pacemaker 24 hours ago. 4. 80 year old chronic obstructive pulmonary disease (COPD) who is on a ventilator.
4 Clients at highest risk for developing hospital acquired MRSA are older adults and those with suppressed immunity, long history of antibiotic use, invasive tubes or lines, or in the ICU. Nurses should follow infection control procedures diligently with these clients.
The nurse is caring for an elderly client after hip replacement surgery. The client is distressed because he has not had a bowel movement in 3 days. Which action by the nurse be most appropriate? 1. Administer the prescribed as-needed milk of magnesia. 2. Ask dietary services to add more fruits and vegetables to the client's tray. 3. Notify the registered nurse 4. Perform a focused abdominal assessment.
4 Constipation may develop as a side effect of anesthesia, pain medication, physiological stress, and/or immobility. The nurse's first priority is to assess the client to determine the cause of this client's constipation. The nurse can administer the as needed laxative once it has been determined to be safe. The RN should be consulted if the focused abdominal assessment indicates a potential complication, such as postoperative ileus.
The nurse performs NG tube insertion using a large-bore NG tube on a hospitalized client with a gastrointestinal bleed. During insertion, after the tube passes the nasopharynx, the client begins to cough and gag. Which action should the nurse take fist? 1. Ask the client to take several small sips of water 2. Continue to slowly advance the tube until placement is reached. 3. Gently remove the tube and reinsert in the other naris if possible. 4. Pull back on the tube slightly and then pause to give the client time to breath.
4 Coughing and gagging commonly occur during NG tube insertion if the tube coils in the throat or slips into the larynx. When this happens, the nurse should pull back on the tube slightly and then pause to give the client time to recover and breathe before advancing the tube.
A client with multiple sclerosis is voicing concerns to the nurse about incoordination when walking. Which of the following instructions by the nurse would be most appropriate at this time? 1. avoid excess stretching of your lower extremities. 2. build strength by increasing the duration of daily exercise 3. let me speak with your health care provider about getting a wheelchair. 4. you should keep your feet apart and use a cane when walking.
4 Multiple sclerosis (MS) is a progressive, demyelinating disease of the central nervous system that interrupts nerve impulses, causing a variety of symptoms. Symptoms may vary, but muscle weakness, spasticity, incoordination, loss of balance. and fatigue are usually present, causing impaired mobility and risk for fall and injury. Walking with the feet apart increases the support base, improving steadiness and gait. Assistive devices, such as a cane or walker, are usually required as demyelination of the nerve fibers progresses.
The nurse is giving unlicensed assistive personnel directions for bathing a client who has a surgical incision infected with methicillin-resistant Staphylococcus aureus (MRSA), Which instructions would be most effective for reducing infection? 1. assist the client to the shower and provide directions to use antibacterial soap. 2. delay the bath until the client has received antibiotic therapy for 24 hours 3. Use a bath basin with warm water and a new wash cloth for each body area 4. use packaged pre moistened cloths containing chlorhexidine to bathe the client
4 Pre-moistened cloths or warm water with chlorhexidine solution should be used when bathing clients infected with methicillin-resistant Staphylococcus aureus or other drug-resistant organisms.
It is 0700 and the nurse is caring for an 84-year-old client with dementia and a fractured hip. The client has been disoriented to time, place, and person since admission. The client moans frequently and grimaces when moving. He is prescribed morphine IV every 2 hours as needed for pain and was last medicated at 0530. He is scheduled for surgery at 1000 to repair the hip fracture, but the consent has not yet been signed. The client's spouse and child are to arrive at 0900. Which intervention should the nurse carry out first? 1. Administer pain medication 2. Call the health care provider to meet with the family to obtain informed consent 3. Complete the preoperative checklist 4. Perform the morning assessment
4 The morning shift assessment should be completed first to collect baseline assessment data (eg, vital signs, lung sounds, level of consciousness)Before surgery, the nurse makes sure informed consent is obtained, performs a complete physical assessment to collect baseline data and determine the client's physiologic and psychologic status, and completes the preoperative checklist.
The nurse is preparing to care for a client with acute myelogenous leukemia who has been going through induction chemotherapy. The client's laboratory results are shown in the exhibit. Which intervention would be a priority for this clients? WBC 1,100/mm, Absolute neutrophil count 400/mm, HGB 8.2 g/dL Platelets 78.000/mm. 1. Administer erythropoietin injection. 2. Minimize venipunctures and avoid intramuscular injections 3. Place sequential compression devices on the legs. 4. Provide a private room and neutropenic precautions.
4. Neutropenic precautions should be used to prevent infection in clients who have low WBC and absolute neutrophil counts and are receiving chemotherapy. Infections in these clients are life threatening. Normal Absolute neutrophil count >1500/mm
The nurse assesses the breath sounds of a 2 day postoperative total laryngectomy client and determines that suctioning is needed to clear secretions. The client is off the mechanical ventilator and is receiving humidified oxygen via a tracheostomy mask. Place the steps for suctioning the tracheostomy tube in the correct order. 1. Apply intermittent suction while rotating the suction catheter while withdrawing 2. If resistance is felt, withdraw the catheter 0.4-0.8 inches 3. Insert catheter the length of the airway without applying suction 4. Place client in semi-Fowlers position 5. Preoxygenate with 100% oxygen
4. Place client in semi-Fowlers position 5. Preoxygenate with 100% oxygen 3. Insert catheter the length of the airway without applying suction 2. If resistance is felt, withdraw the catheter 0.4-0.8 inches 1. Apply intermittent suction while rotating the suction catheter while withdrawing
A nurse administers an IM injection using the Z-track technique. Place the steps in chronological order All options must be used 1. apply gentle pressure at the injection site but do not massage. 2. Inject medication slowly with dominant hand while maintaining traction. 3. Hold the skin taut with non-dominant hand and insert at a 90 degree angle. 4. Pull the skin 1-1 1/2 laterally and away from the injection site. 5. Release the hold on the skin, allowing the layer to slide back to their original position 6. wait 10 seconds after injecting the medication and withdraw the needle.
4. Pull the skin 1-1 1/2 laterally and away from the injection site. 3. Hold the skin taut with non-dominant hand and insert at a 90 degree angle 2. Inject medication slowly with dominant hand while maintaining traction. 6. wait 10 seconds after injecting the medication and withdraw the needle. 5. Release the hold on the skin, allowing the layer to slide back to their original position 1. apply gentle pressure at the injection site but do not massage.
When working with an interpreter, the nurse should apply the following best practices to maximize communication and understanding with the client.
Address the client directly in the first person. Speak in short sentences, pausing to allow the interpreter to speak. Ask only one question at a time. Avoid complex issues, idioms, jokes, and medical jargon. Hold a pre-conference with the medical interpreter to review the goals of the interview. Use a qualified professional interpreter whenever possible.
Droplet precautions are for what 2 diseases?
All meningitis and all influenza Pertusis, Diptheria, Mumps, All Meningitis
With the exception of clients with end-stage renal disease, a serum potassium values >6.5 mEq/L (6.5 mmol/L) in a client who is walking and talking should raise suspicion for an erroneously elevated serum potassium (pseudohyperkalemia) level due to poor hematology technique. A serum potassium lever of 7.0 mEq/L (7.0 mmol/L) constitutes a life-threatening electrolyte imbalance that would cause severe weakness or paralysis, unstable arrhythmias, and eventual cardiac arrest.
Assessment focuses on evaluating cardiac symptoms and muscle strength and should be reported to the RN. It is likely that a repeat blood draw would be prescribed. Pseudohyperkalemia can be avoided on the repeat blood draw through minimal use of a tourniquet and fist clenching and use of a larger gauge needle and heparin-impregnated hematology vials to prevent clotting.
Incisions may take 4-6 weeks to heal. The nurse should teach clients how to care for their incisions by providing the following instructions: Wash incisions daily with soap and water in the shower. Gently pat dry. Itching, tingling, and numbness around the incisions may be present for several weeks due to damage to the local nerves.
Avoid tub baths due to the risk of infection. Do not apply powders or lotions on incisions as these trap bacteria at the incision site. Report any redness, swelling, drainage increase, or if the incision has opened. Wear a supportive elastic hose on the legs and elevate them when sitting to decrease swelling
A nosocomial infection occurs in a hospital (hospital-acquired) or other health care setting and is not the reason for the client's admission. Many nosocomial infections are caused by multidrug resistant organisms. These infections occur 48 hours or more after admission or up to 90 days after discharge.
Clients at greater risk include young children, the elderly, and those with compromised immune systems. Other risk factors include long hospital stays, being in the intensive care unit, the use of indwelling catheters, failure of health care workers to wash their hands, and the overuse of antibiotics. The most common nosocomial infection is urinary tract infection, followed by surgical site infections, pneumonia, and bloodstream infections.
A tracheostomy tube with inflated cuff is used in clients who are at risk for aspiration (eg, who are unconscious or on mechanical ventilation). However, an inflated cuff is uncomfortable for a clients who are awake because it is difficult to swallow or talk. The cuff is deflated when the client is improving, is determined not to be at risk of aspiration, and is awake. Before the cuff is deflated, the client is asked to cough (if possible) to expectorate the oropharyngeal secretions that have build up above the inflated cuff.
In addition, suction is applied through the tracheostomy tube and then the mouth; the cuff is then deflated. additional interventions: Having the client sit upright with the chin flexed slightly toward the chest. Monitoring for a wet or garbled-sounding voice. Monitoring for signs of fever.
To reduce the risk of complications and injury during endotracheal suctioning, the nurse should:
Preoxygenate with 100% oxygen and allow for reoxygenation periods between suction passes. Suction only while withdrawing the catheter from the airway. Use strict sterile technique throughout suctioning. Limit suctioning to <10 seconds on each suction pass.
Contact precautions have what 5 things?
Private room - door can be open Gloves Gown- if giving direct care Handwashing Disposable supplies Dedicated equipment. Methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile diarrhea (D. diff.), Vancomycin-resistant Enterococcus (VRE {bacteria found in stool})
During NG tube insertion, the tube sometimes slips into the larynx or coils in the throat, Which can result in coughing and gagging. The nurse withdraw the tube slightly and then stop or pause while the client takes a few breaths. After the client stops coughing, the nurse can proceed with advancement, asking the client to take small sips of water to facilitate advancement to the stomach.
The client should not be asked to swallow during coughing or aspiration may occur. If resistance or obstruction occurs during tube advancement, the nurse should rotate the tube while trying to advance it. If resistance continues, the tube should be withdrawn and inserted into the other naris if possible.
A nurse is caring for a client who has a chest tube drainage system in place. Where would the nurse observe to assess for tidaling?
Tidaling is the fluctuation that occurs in the water seal chamber in relation to the client's respiratory movements. The level of sterile water rise with inspiration and fall expiration, indicating proper function of the chest tube drainage system. Tidaling movement occurs in section B
Urine specimens are collected aseptically from the port located on the tubing of an indwelling urinary catheter, therefore, the client's collected urine should be measured and discarded. Colonization and multiplication of bacteria within the stagnant urine in the collection bag may occur and cause incorrect results. Some urinary drainage bags are impregnated with an antimicrobial agent to help prevent catheter-associated urinary tract infections. However, the antimicrobial agents can also affect the results of urinalysis and culture.
To collect the urine specimen: 1. Clean the collection port with an alcohol swab 2. Aspirate urine with a sterile syringe 3. Use aseptic technique to transfer the specimen to a sterile specimen cup.
Tuberculin skin test TB The correct procedure for administering a TB intradermal injection is as follows:
Use a 27 gauge 1/4 inch needle with a 1 mL tuberculin syringe. Administer injection on inner forearm at a 10 degree angle with bevel up. Make a wheal (bleb). Avoid rubbing site after injection.
When Ascending stairs with a cane
step up with the stronger leg first Move the cane next, while bearing weigh on the stronger leg Finally move the weaker leg.
