Assignment #2

A nursing documented the following input during her shift- Normal Saline run at 100mL/hour x 4 hours, 2 cups of ice chips, and 8 ounces of tea. Calculate the total intake in millimeters.

880

A nurse's gloves become soiled while providing morning care for a client. Which of the following actions best demonstrates that the nurse applied principles of infection control?

After removing the glove on the non dominant hand, hold the removed glove in the remaining gloved hand

For which of the following clients would the use of Standard Precautions alone be appropriate?

An incontinent client in a nursing home who has diarrhea

During preoperative education, the nurse has taught a client to do leg exercises, How can the nurse best determine whether this teaching has been successful?

Ask the client to demonstrate leg exercises

A nurse is preparing a client for cardiac monitoring. Which of the following actions should the nurse perform?

Assess the client's skin integrity and examine the leads every 8 hours

The nurse has placed the electrodes on the client's chest and connected the cardiac monitor. What is the correct way to check that it it detecting each heartbeat?

Auscultate the heart rate while comparing it to the heart rate on the monitor display

A nurse is testing blood glucose levels of a client with a history of diabetes. The nurse has performed hand hygiene, checked the order, informed the client, and turned on the meter. After removing a test strip from the vial, what action should the nurse perform next?

Confirm that the strip and the meter share the same code

The nurse is donning a pair of sterile gloves. The nurse correctly dons the first glove, but inadvertently inserts the thumb and index finger into the thumb hole of the second glove. The glove remains intact. Which action is most appropriate?

Continue to don the glove, then use the other gloved hand to carefully insert the finer into the proper hole

A nurse is assessing the stoma of a client with an ostomy. What would the nurse assess in a normal, healthy stoma?

Dark red and moist

A nurse using a pulse oximeter to measure a client's SpO2 obtains a reading of 95%. What is the nurse's most appropriate action?

Document this expected assessment finding

A nurse has finished giving care to a client who has a communicable respiratory infection. Which of the following pieces of personal protective equipment should the nurse remove first?

Gloves

A nurse receives an order to apply graduated compression stockings for a client at risk for venous thromboembolism. How should the nurse apply the stockings?

If the client was sitting up, have him or her lie down and elevate feet for 15 minutes before applying stockings

A nurse assesses the abdomen of a client before and after administering a small-volume cleansing enema. What condition would be an expected finding?

Increased bowel sounds

A physician orders the collection of a sputum specimen from a client with a suspected bacterial infection. Which of the following actions best ensures a useable specimen?

Instruct the client to inhale deeply and then cough

A nurse is teaching a preoperative client how to use an incentive spirometer. Which of the following instructions should be included in the teaching plan?

Instruct the client to inhale slowly and as deeply as possible through the mouthpiece without using the nose

The client wearing compression stockings has an order to have a pneumatic compression sleeves applied. What is the nurse's best course of action?

Leave the stockings on and apply the pneumatic compression sleeves over them

The nurse recognizes a need to promote venous return and prevent complications related to venous stasis in a client with decreased activity. What action by the client best accomplishes this goal?

Leg exercises

What method of cardiac monitoring allows the client to be freely mobile?

Telemetry

The nurse is teaching a new nurse about preparing a sterile field. Which action made by the new nurse would indicate further teaching is required?

The new nurse touches the outer 1.5 inches of the drape

A nurse is applying the principles of Standard and Contact Precautions in the care of a hospital client. What action violates these principles?

The nurse removes her gown and them removes the gloves

A client is having difficulty having a bowel movement on a bedpan. What is the physiologic reason for this problem?

The position does not facilitate downward pressure

A nurse assessing a client's respiratory status gets a weak signal from the pulse oximeter. The client's other vital signs are within reference ranges. What is the nurse's best action?

Warm the client's hands and try again

A nurse is feeding a client. Which statement would help a person maintain dignity while being fed?

What part of your dinner would you like to eat first?

A sterile urine specimen for culture and sensitivity has been ordered for a client who has an indwelling urinary catheter. How should a nurse obtain this sample?

Withdraw several milliliters of urine from the port on the collection tubing, using a syringe

A nurse maintains the head of the bed elevated 30 degrees for a client who is receiving continuous tube feedings to prevent

aspiration