week 4 dynamic quiz
a nurse is changing a dressing for a pt who has 2 penrose drains near an abdominal incision. which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation? a. abdominal binder b. montgomery straps c. hypoallergenic tape d. plastic tape
montgomery straps
a nurse is using the braden scale to predict the pressure ulcer risk of a pt in a long-term care facility. using this scale, which of the following parameters should the nurse evaluate? a. incontinence b. mental state c. nutrition d. general physical condition
nutrition
during the insertion of a urinary catheter for a pt, the tip of the catheter brushes against the nurse's arm. which of the following actions should the nurse take? a. wipe the catheter with providone-iodine and continue the catheter insertion b. soak the catheter in chlorhexidine for 15 min and reattempt insertion c. continue with the catheter insertion d. obtain a new catheter and reattempt insertion
obtain a new catheter and reattempt insertion
a nurse is caring for a pt who has fecal impaction. before the digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces? a. carminative b. hypertonic c. oil retention d. sodium polystyrene
oil retention
a nurse is performing a physical exam for a pt . to evaluate the pt's skin moisture the nurse should use which of the following techniques? a. percussion b. auscultation c. inspection d. palpation
palpation
a nurse is preparing to remove an NG tube for a pt who has a partial colectomy, which of the following actions should the nurse take? a. maintain suction while removing the NG tube b. instill 100 mL of air into the NG tube before removal c. pinch the NG tube while removing the tube d. instruct the pt to breathe in and out during the removal of the NG tube
pinch the NG tube while removing the tube
a nurse is preparing to administer a tap water enema to a pt. which of the following action should the nurse take? a. raise the enema bag if the pt experiences cramping b. lubricate 2.54cm (1in) of the tip of the rectal tube prior to insertion c. place the pt in a L sim's position d. don sterile gloves prior to procedure
place the pt in a L sim's position
a nurse is planning to collect a stool specimen for ova and parasites from a pt who has diarrhea. which of the following actions should the nurse take when collecting the specimen? a. instruct the pt to defecate into the toilet bowl b. transfer the specimen to sterile container c. refrigerate the collected specimen d. place the stool specimen collection container in a biohazard bag
place the stool specimen collection container in a biohazard bag
a nurse is preparing to perform postural drainage for the pt. which of the following actions should the nurse take? a. give the pt a bronchodilator immediately after the procedure b. position the pt for the drainage of secretions by gravity c. schedule postural drainage following meals d. instruct the pt regarding the importance of fluid restrictions
position the pt for the drainage of secretions by gravity
a nurse is performing a straight urinary cauterization for a female pt who has a urinary retention. which of the following actions indicates the nurse is maintaining sterile technique? a. apply sterile gloves to open catheter package b. wiping the labia minora in an anteriorposterior direction c. spreading the labia with the dominant hand d. using a cotton ball to wipe the right and left of labia majora
wiping the labia minora in an anteriorposterior direction
a nurse is providing teaching to a newly licensed nurse about removing sutures from a pt's laceration. which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a. "i will use a staple remover and remove each suture individually" b. "bandage scissors are used to cut the sutures" c. "tweezers are necessary only for removing retention sutures" d. " i will clip each suture close to the skin and pull it through from the other side"
" i will clip each suture close to the skin and pull it through from the other side"
a nurse is providing a discharge teaching to a pt who has a prescription for daily wound care via home health services. which of the following statements by the pt indicates an understanding of the teaching? a. "a nurse will show me how to care for my wound" b. "a nurse will stay with me at home during the day" c. "i will call the nurse to change my bed linens" d. "i will call the nurse to help me bathe in the morning"
"a nurse will show me how to care for my wound"
a nurse is preparing a pt for discharge and providing performing dressing changes at home. which of the following statements should the nurse identify as an indication that the pt understands medical asepsis? a. "i will wrap the old dressing in a paper bag and put it in the trash" b. "i will wash my hands before i remove the old dressing and again before putting on the new one" c.: "i'll need to take a pain pill 30 min before changing the dressing" d. "i'll wear sterile gloves when apply new dressing"
"i will wash my hands before i remove the old dressing and again before putting on the new one"
a nurse is instructing a pt about collecting a 24 hr urine specimen for creatine clearance. which of the following statements should the nurse identify as an indication that the pt understands the procedure? a. "the next time i urinate will be the first specimen of the collection" b. "i'll make sure to keep the collection bottle in the container of ice they gave me" c. "once the container is half full, i no longer have to add more urine." d. "it's okay if a piece of toilet paper gets in the bottle. the lab will remove it when they do the test."
"i'll make sure to keep the collection bottle in the container of ice they gave me"
a nurse is teaching a pt about how to remove a soiled dressing. which of the following statements by the pt indicates an understanding of the teaching? a. "i'll wear my non-sterile gloves" b. "i'll use adhesive remover each time" c. "i'll take my pain pill after i change the dressing" d. "i'll fold the dressing with the soiled surface facing outward
"i'll wear my non-sterile gloves"
a nurse is providing teaching to a pt who has chronic constipation and a new prescription for psyllium. which of the following instructions should the nurse provide? a. "the medication is only for short-term use" b."you should eat a low residual diet while taking this medication" c. "mix this medication with water and follow with an additional glass of liquid" d. "the medication's adverse effects of stomach cramps and nausea will go away in time"
"mix this medication with water and follow with an additional glass of liquid"
a nurse is providing teaching to an older pt who has constipation. which of the following statements should the nurse include in the teaching? a. "drink a minimum of 1,000 mL of fluid daily" b. "increase your intake of refined fiber foods" c. "sit on the toilet 30 min after eating a meal" d. "take a laxative every day to maintain regularity"
"sit on the toilet 30 min after eating a meal"
a nurse is caring for a pt who reports feeling a pop after coughing without properly splinting an abdominal incision. on assessment, the nurse notes the pt's wound has eviscerated. which of the following actions should the nurse take? (select all that apply) a. carefully reinsert the intestine through the opening in the wound b. place the pt in a supine position with hips and knees flexed c. leave the room to call the surgeon d. cover the wound and intestine with a sterile moistened dressing e. monitor the pt for manifestations of shock
-place the pt in a supine position with hips and knees flexed -cover the wound and intestine with a sterile moistened dressing -monitor the pt for manifestations of shock
a nurse is teaching a group of older adults at a community center about the functions of the skin. which of the following statements should the nurse include in her teaching? (select all that apply) a. the skin plays an important role in the production of vitamin D b. the dermis contains cells that prevent infection c. the skin protects against bacteria and viruses d. the skin helps regulate the body temp
-the skin plays an important role in production of vitamin D -the skin protects against bacteria and viruses -the skin helps regulate body temp
a nurse is preparing to change a dressing on a pt who is receiving negative pressure wound therapy (NPWT). what sequence of actions should the nurse plan to take? -apply a skin protectant or a barrier film to the skin around the wound -connect the tubing to the transparent film and turn on the NPWT unit -apply sterile or clean gloves to irrigate the wound -remove the soiled dressing and perform hand hygiene -place prepared foam into the wound bed and cover with transparent dressing -turn off the vacuum on the NPWT device and administer the prescribed analgesic
1. turn off the vacuum on the NPWT device and administer the prescribed analgesic 2. remove the soiled dressing and perform hand hygiene 3. apply sterile or clean gloves to irrigate the wound 4. apply a skin protectant or a barrier film to the skin around the wound 5. place prepared foam into the wound bed and cover with transparent dressing 6. connect the tubing to the transparent film and turn on the NPWT unit
a nurse is caring for a pt whose intake and output flow sheet for 0700 to 1500 indicates the following; voided X3: 350mL, 200mL, 150mL; wound drainage 2 tsp, and emesis 2 oz. what is the total output of in mL for this 8hr period? (round to the nearest whole number)
770mL
a nurse on an oncology unit receive report at the beginning of her shift about 4 pts who are post op. which of the following pts should the nurse see first ? a. a pt who is 1 day post op following a lobectomy for a small cell carcinoma and has a chest tube with 35 ml/hr of bright red, bloody drainage b. a pt who is 2 days post op following a colectomy due to colorectal cancer an ostomy bag full of bright red, bloody drainage c. a pt who is 2 days post op following the excision of an abdominal mass and has a portable wound suction device with 20ml/hr of serosanguinous drainage d. a pt who is 1 day post op following the excision of a bladder wall tumor and prostate and has continuous bladder irrigation with 300ml/hr reddish-pink urine
a pt who is 2 days post op following a colectomy due to colorectal cancer an ostomy bag full of bright red, bloody drainage
a nurse is preparing to insert an indwelling urinary catheter for a female pt. which of the following actions should the nurse have the pt perform just before inserting the catheter? a. swallow water b. prepare for a painful sensation c. hold her breath d. bear down gently
bear down gently
a nurse is caring for a pt who has a stage III pressure ulcer on the heel. when preparing to irrigate the wound, which of the following actions should the nurse take first? a. obtain the prescribed irrigation solution b. don personal protective equipment c. check the pt's pain level d. place a waterproof pad under the pt's extremity
check the pt's pain level
a nurse is caring for a pt who has major fecal incontinence and reports irritation in the perianal area. which of the following actions should the nurse take first? a. apply fecal collection system b. apply a barrier cream c. cleanse and dry the area d. check the pt's perineum
check the pt's perineum
a nurse is caring for a post-op pt who has an indwelling urinary catheter for gravity drainage. the nurse notes no urine output in the past 2hrs. which of the following actions should the nurse take first? a. check to determine if the catheter tubing is kinked b. palpate the bladder c. obtain a prescription to irrigate the catheter with 0.9% sodium chloride d. encourage the pt to drink more fluids
check to determine if the catheter tubing is kinked
a nurse is collecting a urine specimen for culture and sensitivity for a pt who has a UTI. the pt has an indwelling urinary catheter in place. which of the following actions should the nurse take? a. withdraw the specimen from the drainage bag b. cleanse the collection port with soap and water c. place the specimen in a clean specimen cup d. clamp the tubing below the collection port
clamp the tubing below the collection port
a nurse is caring for a pt who requires a dressing change. which of the following actions should the nurse take? a. clean the incision from bottom to top b. apply sterile gloves prior to opening dressing packages c. remove the tape by pulling away from the wound d. clean the drain site from the center outward
clean the drain site from the center outward
a nurse is providing teaching about proper care to a pt who has a new colostomy. which of the following pieces of info should the nurse include in the teaching? a. change the colostomy bag following breakfast b. cleanse the skin around the stoma with warm water. c. change the pouch every day d. place an aspirin in the ostomy pouch to decrease odor
cleanse the skin around the stoma with warm water.
a nurse is collecting a specimen for culture from a pt's infected wound. which of the following actions should the nurse perform? a. wear sterile gloves when collecting specimen b. cleanse the wound with 0.9% sodium chloride irrigation c. allow the collection swab to absorb old exudate d. rotate the collection swab over the edges of the wound
cleanse the wound with 0.9% sodium chloride irrigation
a nurse is caring for a pt who had a mastectomy and has a self-suction drainage evacuator in place. which of the following actions should the nurse take to ensure proper operation of the device? a. irrigate the tubing with sterile normal water once during each shift b. cleanse the opening with soap and water after emptying c. maintain the tubing above the level of the surgical incision d. collapse the device to remove the air after emptying
collapse the device to remove the air after emptying
a nurse is providing discharge teaching to a pt who is post op and has a new prescription for an oral opioid analgesic. which of the following information should the nurse include as a rationale for increasing the pt's daily intake of fiber? a. fiber binds with the medication to relieve pain b. dietary fiber prevents nausea by opioids c. fiber promotes absorption of opioids d. dietary fiber helps prevent constipation
dietary fiber helps prevent constipation
a nurse is caring for a pt who is producing large amounts of urine. the nurse should document this finding as which of the following? a. retention b. oliguria c. diuresis d. dysuria
diuresis
a nurse is replacing the surgical dressing on a pt who had abdominal surgery. which of the following actions should the nurse take? a. don clean gloves to remove the old dressing b. loosen the dressing by pulling the tape away from the wound c. remove the entire old dressing at once d. open sterile supplies after applying sterile gloves
don clean gloves to remove the old dressing
a nurse is providing teaching to a pt who has constipation. which of the following instructions should the nurse include? a. use bismuth subsalicylate regularly b. consume a low fiber diet c. eat yogurt with live cultures d. use bisacodyl suppositories regularly
eat yogurt with live cultures
a nurse is caring for a pt who has acute exacerbation of crohn's disease. which of the following actions should the nurse take? a. ensure bowel rest b. offer sparkling water c. administer stool softener d. offer plain warm tea frequently
ensure bowel rest
a nurse is working with the facility's language interpreter to explain a wound-care procedure to a pt who does not speak the same language as the nurse. which of the following actions should the nurse take when describing the procedure to the pt? a. make eye contact with the interpreter b. break sentences into shorter segments to allow time for interpretation c. ensure the interpreter and the pt speak the same dialect d. speak in loud tone of voice
ensure the interpreter and the pt speak the same dialect
a nurse is caring for a pt who is having difficulty breathing. the nurse should assist the pt to which of the following positions? a. supine b. lateral c. fowler's d. trendelenburg
fowler's
a nurse is caring for a pt who is post op following vascular surgery on the L femoral artery. the nurse should identify that the surgical wound should be cleansed in which of the following directions? a. from the middle of the thigh toward the wound b. from the L lower abdomen quadrant toward the wound c. from the L hip toward the wound d. from the wound toward the surrounding skin
from the wound toward the surrounding skin
a nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. which of the following pieces of info should the nurse include in the teaching? a. the wound edges are well-approximated b. the wound is closed at a later date c. a skin graft is placed over the wound bed d. granulation tissue fills the wound during healing
granulation tissue fills the wound during healing
a nurse in the ER is assessing a pt who reports diarrhea and decreased urination for 4 days. which of the following actions should the nurse take to assess the pt's skin turgor? a. push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to become pink b. grasp the skin fold on the chest under the clavicle, release it, and note whether it springs back c. press the skin above the ankle for 5 seconds, release it and note the depth of the impression d. measure the skinfold thickness on the upper arm using a pair of calibrated skinfold calipers
grasp the skin fold on the chest under the clavicle, release it, and note whether it springs back
a nurse is changing the dressing for a pt recovering from an appendectomy following a ruptured appendix. the pt's surgical wound is healing by secondary intention. which of the following observations should the nurse report to the provider? a. tenderness when touched b. pink, shiny tissue with a granular appearance c. serosanguineous drainage d. halo of erythema on the surrounding skin
halo of erythema on the surrounding skin
a nurse is caring for a pt who is receiving a blood transfusion. the pt reports flank pain, and the nurse notes reddish-brown urine in the pt's urinary catheter bag. the nurse recognizes the manifestations as which of the following types of transfusion rxns? a. hemolytic b. febrile c. circulatory overload d. sepsis
hemolytic
a nurse is caring for a pt who has a stage II pressure ulcer. which of the following wound dressing should the nurse apply to the ulcer? a. hydrocolloid b. collagen c. calcium alginate d. proteolytic enzyme
hydrocolloid
a nurse is caring for a pt who is 48hr post op following a small bowel resection. the pt reports gas pains in the periumbilical area. the nurse should plan care based on which of the following factors contributing to this post op complication? a. blood loss b. NPO status after surgery c. nasogastric tube suction d. impaired peristalsis of the intestines
impaired peristalsis of the intestines
a nurse is preparing to administer a cleansing enema to a pt who is scheduled for a diagnostic procedure. which of the following action should the nurse take? a. lubricate up to 3.2cm (1.25in) of the tip of the rectal tube b. position the pt on their right side c. insert the tip of the tubing 8cm (3.1inches) d. hold the enema container 61cm (24in) above the rectum
insert the tip of the tubing 8cm (3.1inches)
a nurse is cleaning a pt wound by swabbing from the area of least contamination to an area greater contamination. which of the following rationales should the nurse identify for using this technique? a. preventing the transfer of microorganisms to the nurse b. keeping the microorganisms from entering the wound c. apply minimal pressure to the wound d. keeping excess moisture from entering the wound
keeping the microorganisms from entering the wound
a nurse is preparing to insert an indwelling urinary catheter for a male pt. which of the following locations should the nurse secure the urinary catheter? a. lateral thigh b. lower abdomen c. mid-abdominal region d. medial thigh
lower abdomen
a nurse is planning care for a pt who is post op and has a history of poor nutritional intake. which of the following actions should the nurse include in the plan of care to promote wound healing? a. limit total caloric intake 25kcal/kg of body weight b. provide an intake of 500mg/day of vitamin E c. limit fluid intake to 20mL/kg of body weight per day d. provide a protein intake of 1.5g/kg of body weight per day
provide a protein intake of 1.5g/kg of body weight per day
a nurse is changing the dressing for a pt who is 3 days post op following a cholecystectomy. the nurse observes yellow, thick drainage on the dressing. the nurse should document which of the following types of drainage? a. sanguineous exudate b. serous exudate c. serosanguineous exudate d. purulent exudate
purulent exudate
a nurse is caring for a pt who is receiving a continuous enteral feeding through a NG tube and develops diarrhea. which of the following actions should the nurse take? a. change the tube feeding bag every 48hrs b. chill the formula prior to administration c. increase the infusion rate d. request a prescription for an isotonic enteral nutrition formula
request a prescription for an isotonic enteral nutrition formula
a nurse is assessing a pt's incision and observes the drainage to blood-tinged. which of the following terms should the nurse use to document this finding? a. sanguineous b. purulent c. serous d. hyperemia
sanguineous
a nurse is caring for a pt who is dehydrated. the nurse should expect that insensible fluid loss of approximately 500 to 600 mL occurs each day through which of the following organs? a. kidneys b. lungs c. gastrointestinal tract d. skin
skin
a nurse is reviewing the lab data of a pt who has a fever and watery diarrhea. which of the following results should the nurse report to the provider? a. calcium 9.5mg/dL b. sodium 150 mEq/L c. potassium 4 mEq/L d. magnesium 1.5mEq/L
sodium 150 mEq/L
a nurse delegated the task of emptying an indwelling urinary catheter drainage bag to an assistive personnel (AP). the nurse observes the AP emptying the bag without wearing gloves. which of the following actions should the nurse take? a. notify the charge nurse about the incident b. insist that the AP attend an in-service training about standard precautions c. talk with the AP about the sterile technique used d. observe the AP a second time and intervene if the technique remains the same
talk with the AP about the sterile technique used
an assistive personnel (AP) is helping a nurse care for a female pt who has an indwelling urinary catheter. which of the following actions by the AP indicates need for further teaching? a. the AP uses soap and water to clean the perineal area b. the AP tapes the catheter to the pt's inner thigh c. the AP hangs the collection bag at the level of the bladder d. the AP ensures there are no kinks in the drainage tubing
the AP hangs the collection bag at the level of the bladder
a nurse is planning care for a pt who has a wound infection following abdominal surgery. to promote healing and fight infection, which of the following vitamins and minerals should the nurse increase in the pt's diet? a. vitamin C and zinc b. vitamin D c. vitamin K and iron d. calcium
vitamin C and zinc