Exam 3 FN
Solve for X: 2 : 17 = x : 7
0.82 ** 17x = 14 ** ** 14 / 17 = 0.82 **
correct order the steps involved in administering an intradermal injection.
1. Cleanse site with antiseptic swab. 2. Using nondominant hand, stretch skin over site with forefinger. 3. Insert needle at a 5- to 15-degree angle into the skin until resistance is felt. 4. Advance needle through epidermis to 3 mm. 5. Inject medication slowly. 6. Note the presence of a bleb.
The nurse is removing a Foley catheter where 10 mL of fluid was inserted into the balloon when the RN placed the foley before surgery. How much fluid should you expect to remove when deflating the balloon?
10 mL
What is the usual time limit for sending a urine specimen to the lab before needing it to be refrigerated?
15 min
6 Tbsp = __________ tsp
18 tsp ** 3 tsp = 1 tbsp** **6 x 3** **Large to Small move right or multiply** **Small to Large move left or multiply**
A medication order is for 0.5 g PO every 12 hours. The medication is available in 250 mg tablets. How many tablets should the nurse administer?
2 tablets **0.5 g = 500 mg** **250 / 500 = 2**
When inserting a urinary catheter into a female patient, how far should the nurse initially insert the catheter?
2 to 3 inches
2.5 kg = ______ g
2,500 g **Large to Small move right or multiply** **Small to Large move left or multiply**
The average adult urinary output is
2200 mL to 2700 mL
1 tbsp = __________ tsp
3 tsp
What is the minimum amount of expected urinary output in one hour?
30 mL/hr
1 tsp = __________ mL
5 mL
When should the RN review the patient's medication list with the patient? Before Transfer During admission, before transfer, at discharge, and when new medications are ordered. During admission At discharge
During admission, before transfer, at discharge, and when new medications are ordered.
T/F If the patient has a cast on his left leg and is using a cane, he/she should hold the cane in their left hand?
FALSE **Pt should hold cane in their RIGHT hand since LEFT leg is bad**
Which nursing action has the highest priority for a patient receiving medication via a nasogastric feeding tube? Flush with 30 mL of water before and after feedings. Keep head of bed elevated above 30 degrees for at least 30 to 60 minutes after feeding. Wait 30 to 60 minutes after feeding to reconnect to suctioning. Change the feeding pump bag and tubing every 24 hours
Flush with 30 mL of water before and after feedings **Flushing before and after feeding ensures patency of the feeding tube and correct delivery of the medication. Although keeping the head of the bed elevated is an important step in preventing aspiration, the patency of the tube is a higher priority in correct administration of medication through this route. While waiting the correct amount of time before connecting suctioning and changing the bag on an appropriate schedule are important, flushing is a much higher priority.**
When performing catheter care, what step helps prevent traction on the catheter and CAUTI? Wash the meatus with soap and water. Start cleansing at the meatus and move toward the rectum. Grasp the catheter with two fingers to stabilize the catheter. Retract the foreskin before cleansing.
Grasp the catheter with two fingers to stabilize the catheter. **All options help prevent CAUTI, but only option "C" prevents unnecessary traction on the catheter. Pulling on the catheter causes discomfort for the patient and can damage the urethra and the bladder neck.**
The nurse realizes that her patient needs to improve his or her mobility as quickly as possible. This is because the nurse realizes that physical activity: (Select all that apply.) Improves Joint motion Increases social activity Enhances mental stimulation Decreases circulation
Improves Joint motion Increases social activity Enhances mental stimulation
With dehydration, will you see an increase or decrease in specific gravity lab value?
Increase
The nurse classifies a pressure ulcer according to the type of tissue in the wound bed. What does it indicate if the wound bed has granulation in it? Movement toward healing The presence of significant infection Colonization by bacteria Wound needs debridement
Movement toward healing
The nurse contacts the prescriber and receives a STAT telephone order for a medication. What is the first thing the nurse should do after writing down the order? Locate the prescriber and obtain a signature. Prepare the medication for administration. Contact the pharmacy to have the medication sent to the nursing unit STAT. Read back the telephone order to the prescriber.
Read back the telephone order to the prescriber. **After receiving a verbal or telephone order, the first thing the nurse should do is read back the order to verify what was said. Once the order has been verified, the nurse would prepare the medication or would contact the pharmacy in the event that the medication is not readily available. The prescriber would be expected to countersign the order within 24 hours.**
The nurse is caring for a patient who has an order for an acetaminophen rectal suppository. Which finding contraindicates the use of a rectal suppository? Rectal hemorrhoids Presence of a fever Rectal bleeding Constipation
Rectal bleeding **Rectal suppositories are contraindicated in patients with rectal, bowel, or prostate surgery or with active rectal bleeding.**
A patient developed a 2-cm stage 1 pressure ulcer over the sacrum. A transparent dressing has been in place for 2 days. The nurse on the evening shift notices that the skin under the dressing appears broken. The patient complains of tenderness when the nurse palpates the skin. The nurse also notices drainage under the transparent film. What action should the nurse take in this situation? Remove the dressing and obtain an order for a wound culture. Record observations and keep the dressing in place. Increase the frequency of changing the transparent dressing. Consider irrigating the wound.
Remove the dressing and obtain an order for a wound culture. **The wound has advanced from a stage I to a stage II ulcer and shows signs of infection. Removal of the dressing is necessary. A wound culture will determine the type of bacteria growing in the wound. It would also be appropriate to consider using a different type of dressing. Irrigation is likely not necessary for a stage II pressure ulcer**
Which task would be most appropriate for the nurse to delegate to the nursing assistive personnel (NAP)? Administering oral medications Documenting patient's response to medication Reporting any changes in patient's status after medication administration Calling the pharmacy to clarify the correct dose of medication
Reporting any changes in patient's status after medication administration **The NAP has a limited scope of practice; the most appropriate delegation is to have the NAP report changes in the patient's status.**
Please list 9 rights of medication administration.
Right Patient Right Drug Right Dose Right Route Right Effects Right Time Right to Refusal Right Documentation Right Education
A patient has asked for a pain medication to relieve the discomfort from her abdominal incision. She has experienced nausea and vomiting since this morning after several bites of her soft diet breakfast. She last received a dose of her ordered oral analgesic 4 hours ago about one hour before breakfast. The medication, hydrocodone 10 mg PO, is ordered every 4h prn. Which of the following rights of drug administration will most likely be a concern for the nurse caring for this patient? Right Route Right Dose Right Patient Right Time
Right Route
A nurse needs to order a serum trough level to be drawn on a patient. When should he or she schedule the blood draw to be obtained? 2 hours after the medication is given Right before the next dose of the drug is due. Midpoint between the times the drug doses are given. When the serum level is scheduled to plateau, usually early in the morning.
Right before the next dose of the drug is due.
An older diabetic patient with a lot of abdominal fat underwent abdominal surgery 4 days ago involving an 8-inch vertical incision. The nurse would be most concerned if which observation of the incision was made? The incision line is slightly pink and elevated where the staples are located. Serosanguineous drainage has increased since 2 days ago. The incision line has a light crust on it. The patient's pain level has changed from "5" yesterday to "2" today.
Serosanguineous drainage has increased since 2 days ago. *An increase in serosanguineous drainage is an early indication that the wound is not healing as expected, and that dehiscence could occur. The patient is obese, is advanced in age, and has diabetes—all of which are stressors that could cause a negative outcome.*
An elderly patient who spends most of his waking hours in a chair is at risk for skin breakdown on his buttocks. What is the most appropriate action that the nurse should initiate with this patient? Set a timer to ring at 15- to 20-minute intervals to remind the patient to change position. Teach the patient to change position with every television commercial. Assess the outcomes of skin-focused interventions every 2 to 3 days. To relieve pressure, place an inflatable ring on his chair.
Set a timer to ring at 15- to 20-minute intervals to remind the patient to change position. **A timer provides an audible cue to change position. An elderly person may forget, may doze off, or may be distracted by involvement in an activity, causing him to lose track of time. There are many commercials on television, and telling the patient to move with every television commercial could be quite taxing. Outcomes of interventions should be assessed every shift or more frequently, and placement of an inflatable ring may cause pressure ulcers on other areas not already affected.**
What should the nurse do when removing intermittent sutures? Snip the suture as close to the skin as possible. Snip both sides of the suture before removing. Snip the suture as close to the knot as possible. Pull up the knot to apply as much tension as possible.
Snip the suture as close to the skin as possible.
The risk for catheter-associated UTI can be reduced by using ___________ when inserting the catheter
Sterile Technique
Which intervention is appropriate when an indwelling urinary catheter is secured in a male patient? Secure the catheter drainage tubing to the lower leg. Attach the securement device above the catheter bifurcation. Tape the catheter tubing to the lower abdomen, avoiding traction. Secure the catheter tubing to the upper inner thigh with slight traction.
Tape the catheter tubing to the lower abdomen, avoiding traction. **Securing the catheter, not the drainage tubing, reduces the risk of urethral erosion, CAUTI, or accidental catheter removal. Attachment of the securement device at the bifurcation is recommended to prevent catheter occlusion. Securement of the male catheter to the abdomen reduces traction on the urethra and prevents urethral injury. Catheter traction should always be avoided to minimize risk for urethral trauma.**
A patient needs to have his abdominal wound irrigated. Which part of the procedure may the nurse delegate to nursing assistive personnel (NAP)? Documenting the description of the wound Packing the wound with sterile gauze pads Taping the dressing once the wound is covered Performing wound irrigation
Taping the dressing once the wound is covered
The nurse is checking for discoloration on a patient who has darkly pigmented skin. The nurse would be administering appropriate care if which technique was used? The nurse uses a gloved hand to feel for warmth or change in tissue texture. The nurse uses a fluorescent light for the skin assessment. The nurse places the patient in a 30-degree lateral position for the assessment. The nurse checks for discoloration an hour after the patient is turned.
The nurse uses a gloved hand to feel for warmth or change in tissue texture. **Because of the darker skin tones, the nurse must feel for warmth in the suspected area or a change in texture because a change in color may not be visible. A fluorescent light is not appropriate. The lateral position is not indicated, and any assessment for discoloration would be done as soon as a patient is changed from one position to another.**
When a patient self-administers a vaginal suppository, which behavior would require further teaching? (Select all that apply.) The patient voids before insertion. The patient lies on her left side. The patient uses her dominant hand to insert the suppository along the posterior wall of the vaginal canal. The patient inserts the suppository 5 cm (2 inches) into the vaginal canal.
The patient lies on her left side. The patient inserts the suppository 5 cm (2 inches) into the vaginal canal. **Answer "B" describes the correct position for a rectal suppository, and answer "D" explains the correct distance for insertion of a rectal suppository.**
What is the goal of computerized physician order entry (CPOE)? To increase the number of medication orders To decrease the number of medication orders To cause less inconvenience for prescribers To prevent medication errors and enhance patient safety
To prevent medication errors and enhance patient safety **CPOE systems may significantly reduce medication error and enhances patient safety by eliminating the need for handwritten orders. The use of CPOEs does not increase or decrease the number of medication orders and was not instituted to cause less inconvenience for prescribers.**
One lumen is used to instill medication for irrigation A. Single Lumen Catheter B. Double Lumen Catheter C. Triple Lumen Catheter
Triple Lumen Catheter
T/F Catheter use has been associated with increased risk for UTIs
True
Prevention of Medication Errors includes all except which action? Use workarounds to increase efficiency and reduce steps in the process. Preparation of medication for only one patient at a time. Minimize distractions during medication administration. Stay up to date on latest medication administration practices.
Use workarounds to increase efficiency and reduce steps in the process.
An obese patient is at risk for skin breakdown and subsequent pressure ulcers. Which strategies should the nurse who is caring for this patient include in his care? Using a liftsheet and maintaining the head of the bed no higher than 30 degrees Decreasing dietary protein intake and increasing his fluid intake to 2000 mL per day Turning the patient every 4 hours and increasing caloric intake to maintain normal tissue status Increasing the patient's vitamin and mineral intake and keeping the patient in high Fowler's position
Using a liftsheet and maintaining the head of the bed no higher than 30 degrees **Use of a lift sheet will reduce friction on the patient's skin when repositioning him. By keeping the head of the bed no higher than 30 degrees, you prevent the patient from sliding down and exerting a shearing force on his coccyx, which could lead to a pressure ulcer. Dietary protein would be increased, not decreased, and increased fluids would be recommended. The patient should be turned every 2, not 4, hours. However, caloric increase would not be provided for an already obese patient. Vitamins and minerals are important, but the patient would not be placed in high Fowler's position.**
The recommended method for IM injection that prevents leakage of medication into subcutaneous tissues is ___________.
Z track
After administering a medication via IV piggyback, the nurse notes infiltration of medication into the subcutaneous tissue. Agency policy indicates the need for extravasation care including: administer antihistamine or epinephrine. assess injection site for potential injury. administer phentolamine around infiltration site. start new IV site first.
administer phentolamine around infiltration site. **Traditional extravasation care includes administration of phentolamine around the infiltration site.**
ad lib
as desired
prn
as needed
When assessing for polypharmacy in older adults, the nurse should: (Select all that apply.) ask about over-the-counter (OTC) drugs or herbal supplements. ask if they see more than one health care provider. ask which pharmacy they use. have the pharmacist collect the information.
ask about over-the-counter (OTC) drugs or herbal supplements. ask if they see more than one health care provider. **Older adults experience polypharmacy when they seek relief from a variety of symptoms (e.g., constipation, insomnia, pain) and see multiple health care providers. When determining polypharmacy, review all older adults prescribed medications and all other supplements and OTC medications.**
noc
at night
po
by mouth
CSQI is an appropriate route for administration of: fluids to older adults. antibiotics. insulin to infants. all IV medications.
fluids to older adults **CSQI is used to administer hypertonic fluids to older adults to address dehydration. CSQI is not suitable for use with infants. The medications most commonly administered with CSQI are insulin and opioids.**
The patient with a nasogastric (NG) tube in place may experience skin breakdown: behind the ears in the nose on the tongue around the lips
in the nose
With dehydration the patient may exhibit the which of the following signs? (Select all that apply) increased skin temperature anuria decreased pulse rate dry conjunctivae
increased skin temperature anuria dry conjunctivae
The nurse is caring for a patient who is bleeding. To control bleeding, she would apply a _______ dressing. pressure alginate foam hydrocolloid
pressure
The nurse is changing a surgical dressing and is cleansing the wound. She knows that: she should start at the center of suture line and clean away from suture line she should start at one end of the incision line and swab the entire length. she should work in a circular motion around the incision line the incision lines should be cleansed last.
she should start at the center of suture line and clean away from suture line
The nurse is caring for four patients during a shift. Which of the following patients is at greatest risk for developing a pressure ulcer? The patient who is bedridden, but who turns himself randomly The patient whose braden Scale score is 18 the patient whose Braden Scale score is 8 The paitent who can ambulate to the bathroom independently
the patient whose Braden Scale score is 8 **The lower the #, the higher the risk**
Which situation noticed during evaluation would determine that the staples or sutures should remain in place? the patient is anxious about their removal. the wound edges are separated. A cosmetically aesthetic result would not be achieved. No drainage or erythema is present.
the wound edges are separated.
tid
three times per day
A patient has nonreactive hyperemia. What would be expected to be included in the patient's immediate care? An ordered increase in the amount of protein consumed Use of the Braden Scale Immediate transfer to a special pressure mattress Padding around the area susceptible to breakdown
use of the braden scale **The patient's tissue does not return to a pinkish color after compression; this indicates that the patient is at risk for skin breakdown. Use of the Braden Scale to perform a comprehensive evaluation would be recommended. Assessment is the priority. Additional protein would not be ordered at this time. Placing the patient on a special mattress or padding the area is not appropriate at this time. The patient needs to be assessed before appropriate interventions can be determined.**
When should a nurse consider culturing a wound? when the patient is afebrile When the exudate is not present when the tissue is clean and dry when the surrounding area shows inflammation
when the surrounding area shows inflammation
230 mL = ________ L
0.23 L **Large to Small move right or multiply** **Small to Large move left or multiply**
430 mcg = _______ mg
0.43 mg **Large to Small move right or multiply** **Small to Large move left or multiply**
When administering medication through an enteral tube, always flush the tubing with ______ mL of water after each medication. After the last medication, flush the tubing with ______ mL of water.
30 to 60; 15 to 30
0.4 g = ________ mg
400 mg **Large to Small move right or multiply** **Small to Large move left or multiply**
A patient with a large abdominal incision is being discharged. Which statement by the patient indicates that teaching by the nurse has been effective? "Now that my incision is without staples, it is healed and strong." "As long as I don't have pain, I can do just about anything I want." "I don't have to worry about further drainage, now that the staples are out." "I need to avoid lifting anything heavy for at least several weeks."
"I need to avoid lifting anything heavy for at least several weeks."
Oral medications come in many forms. Choose the oral forms from the list below. A. Capsules B. Tablet C. Suppository D. Elixir
Capsules Tablets Elixirs
Patients are at risk for developing pressure ulcers on which areas of the body? SELECT ALL THAT APPLY Genitalia Ears Nares Coccyx
Genitalia Ears Nares Coccyx
Catheter is not left in. One time use to drain the bladder: A. Single Lumen Catheter B. Double Lumen Catheter C. Triple Lumen Catheter
Single Lumen catheter
The patient is admitted with an open pressure ulcer with necrotic tissue around the base of the wound. How would the nurse classify this ulcer? Wound that cannot be staged Stage II pressure ulcer Stage III pressure ulcer Stage IV pressure ulcer
Wound that cannot be staged **It would need debridement**
Please select all of the principles of safety a nurse must include on the patient's chart when they are being transferred to the operating room for a surgical procedure. Date Medical Record number Time patient is leaving the floor. Patient Name
all of them
With fluid volume overload, will you see an increase or decrease in specific gravity lab value?
decrease
gtt
drop
When medication is administered via CSQI, sites for children are rotated: when the CSQI needle falls out. every 48 to 72 hours. every 2 to 7 days. when the infusion is complete.
every 48-72 hours **Current practice indicates that for children receiving medication via CSQI, the site is cleansed and is changed every 48 to 72 hours, or when inflammation is noted.**
bid
twice a day
When evaluating a patient, the nurse observes an unexpected outcome of treatment when the surrounding skin of an ulcer becomes macerated. The nurse should: use dressings with increased moiture absorption obtain a wound culture monitor the patient for systemic signs and symptoms apply pressure-reducing devices
use dressings with increased moiture absorption
The nurse is ready to administer a patient's morning medication when the patient states, "Please leave the medication on my table. I will take it after I use the restroom." Which is the most appropriate response from the nurse? "I will bring the medication back to your room once you return from the bathroom." "It will take only a minute to swallow the medication before you go to the bathroom." "That's fine, please take it the minute you get back from the restroom. I will be back to check on you." "I will wait until noon, when you have more medication ordered, and will bring it back to you then."
"I will bring the medication back to your room once you return from the bathroom." **The nurse should remain with the patient as the patient takes the medication. It is not acceptable to leave medication at the bedside unless a prescriber order to do so has been received.**
The patient asks the nurse why he has a drain in his abdomen after surgery. Which response by the nurse is most accurate? "The drain removes abdominal fluids to reduce stress on the suture line." "You have a drain to prevent any swelling of the surgical area." "The drain allows the antibiotics that were instilled in the wound to drain." "The drain removes fluid from the surgical area to promote healing."
"The drain removes fluid from the surgical area to promote healing." **The drain removes any accumulation of drainage from the wound bed, and this promotes wound healing. The answer is truthful and uses no technical words.**
65% of 450 =
292.5 ** 0.65 x 450 **
A patient has a pressure ulcer that contains necrotic tissue. Nursing care for this patient would be correct if which measure was taken to remove dead tissue from the wound bed? Use of a wick to remove moisture from the decayed tissue Use of hydrogen peroxide to loosen the necrotic tissue Vigorous sterile scrubbing of the wound bed A gentle topical method that removes dead tissue
A gentle topical method that removes dead tissue
The nurse is caring for a patient who has a dressing over a surgical wound created the night before. The dressing has never been changed. The physician has written an order for the dressing to be changed at 0600 the next morning. What should the nurse do first? Administer an analgesic 30 minutes after a dressing change. Administer an analgesic 30-45 minutes before a dressing change. Culture the wound if wound exudate is present. change the dressing so she can assess the wound.
Administer an analgesic 30-45 minutes before a dressing change.
A patient is being admitted to the hospital for a surgery schedule the following morning. Which action by the nurse is most important? Ask the nursing assistant to obtain vital signs Ask the nursing assistant to obtain the health history. Orient the patient to the room and equipment. Ask the patient about allergies.
Ask the patient about allergies.
In the event that a medication error occurs, the nurse should do the following first: Contact the prescriber to inform him/her of the error. Contact the manager or supervisor of the area where the error occurred. Assess and examine the patient. Complete the institution's incident or occurrence report.
Assess and examine the patient. **The nurse should always assess and examine the patient immediately after an error has occurred. Once the patient's safety and well-being have been assessed, the nurse should contact the prescriber. Completing the occurrence or incident report and notifying the manager or supervisor would take place next.**
The nurse notes that urine does not flow after a female patient is catheterized. The nurse believes that the catheter has been kinked due to the patient lying on it. Which action should the nurse take? Deflate the balloon and then reinsert it. Irrigate the catheter with saline. Assess that the tubing is not leaking and re-position the patient. Insert a new catheter.
Assess that the tubing is not leaking and re-position the patient.
A patient with a large surgical wound that is healing by secondary intention has an order for the wound to be packed with gauze that has been moistened in saline. Which of the following steps in packing a wound is incorrect? Pack the wound gently. Cover moist gauze packing with dry sterile gauze. Avoid placing gauze into the sinus tract or an undermined area of the wound. In the case of a deep wound, wear sterile gloves.
Avoid placing gauze into the sinus tract or an undermined area of the wound. **It is important to be sure that any dead space from sinus tracts, undermining, or tunneling is loosely packed with gauze. Loose packing facilitates wicking of drainage. A dry cover gauze pulls moisture from the wound. It is necessary to wear sterile gloves when packing a deep wound**
Which activities related to urinary elimination may be delegated to a nursing assistant? Reporting to the physician the patient is having blood in their urine. Inserting a Foley Catheter Obtaining a midstream urine specimen Documentation of an assessment of foley catheter care.
Obtaining a midstream urine specimen
What are QSEN guidelines?
Patient Centered Care Evidence Based Practice Teamwork & collaboration Safety Informatics Quality Improvement
With fluid volume overload the patient may exhibit which of the following signs? (Select all that apply). Bounding pulse rate vomiting, diarrhea, abdominal cramping Flat neck veins Periorbital edema
Bounding pulse rate vomiting, diarrhea, abdominal cramping Periorbital edema
mcg
microgram
npo
nothing by mouth
A ___________________ is a noninvasive alternative for management of male urinary incontinence. Because it is noninvasive, the risk for UTI is decreased. The device fits over the penis and connects to a small collection bag that attaches to the leg with a strap, or to a standard urinary collection bag that hangs on the bed frame below the level of the bladder.
Condom Catheter
Normal wound healing requires a physiological wound environment that includes which of the following? (Select all that apply.) Control of bacterial burden Adequate moisture Temperature control Tissue eschar
Control of bacterial burden Adequate moisture Temperature control **A healthy physiologic wound environment includes adequate moisture, control of temperature, pH, and bacterial burden to promote healing. Eschar or necrotic tissue forms in deep infected wound**
The nurse answers the patient's call light to find the patient agitated and stating that she "felt something pop." the nurse finds that the patient's abdominal surgical wound has eviscerated. What should the nurse do? Cover the wound with a moist saline dressing. Cover the wound with a dry sterile dressing. Notify the surgeon when he makes rounds. Try to reinsert the abdominal contents.
Cover the wound with a moist saline dressing.
A patient was originally in the intensive care unit and has been moved out to the general surgery unit. The patient is obese and has an 8-inch abdominal incision. The nurse makes rounds and begins to check the patient's dressing when the patient tells the nurse, "I think I felt something just give way in my belly." The nurse removes the gauze dressing over the incision and sees that the wound has Serosanguineous drainage. What should be her next step? Notify the patient's health care provider. Check the patient's blood pressure and heart rate. Cover the wound with gauze moistened in sterile saline. Instruct the patient to lie on the right side.
Cover the wound with gauze moistened in sterile saline. **The first step is to cover the wound with gauze moistened in saline to protect the wound. The nurse should then have the patient lie still without turning. It is important to monitor vital signs and notify the health care provider**
While removing the patient's staples, the nurse notices that the incision starts to open larger than the width of two staples. Which action should the nurse initially take? Place several Steri-Strip to close the open area. Remove one more staple to see whether the open area enlarges. Notify the health care provider of the opening in the wound. Palpate the edges of the wound.
Place several Steri-Strip to close the open area. **Steri-Strip would be applied first to prevent any further opening of the incision. The patient's physical needs must be met first. The health care provider would be notified, and the wound status documented. No further staples should be removed at this time. The staples may need to remain in longer.**
What should the nurse do to reestablish the vacuum of the Hemovac system after emptying? Pin the drainage tubing to the patient's gown. Place a safety pin on the part of the drain outside the body. Place the evacuator on a flat surface with open outlet facing upward and press downward until the bottom and top are in contact. Replace the cap immediate after emptying.
Place the evacuator on a flat surface with open outlet facing upward and press downward until the bottom and top are in contact.
The nurse knows that which of the following factors contribute to the development of pressure ulcers? SELECT ALL THAT APPLY Poor nutrition Moisture and ammonia Uncontrolled pain Immobility Friction and Shear
Poor nutrition Moisture and ammonia Immobility Friction and Shear
Which nursing intervention decreases the risk for catheter-associated urinary tract infection (CAUTI)? (Select all that apply.) Daily cleansing of the urinary meatus Hanging the urinary drainage bag below the level of the bladder Changing the urinary drainage bag daily Irrigating the urinary catheter with sterile water Emptying the drainage bag using a separate receptacle for each patient
Daily cleansing of the urinary meatus Hanging the urinary drainage bag below the level of the bladder Emptying the drainage bag using a separate receptacle for each patient
What is the best nursing action when there is no urine flow after an indwelling urinary catheter is inserted into a female patient? Remove the catheter and start all over with a new kit and catheter. Determine whether the catheter is in the vagina, leave it there, and start over with a new catheter. If misplaced, pull the catheter back and reinsert at a different angle. Ask the patient to bear down, and insert the catheter farther.
Determine whether the catheter is in the vagina, leave it there, and start over with a new catheter. **If misplaced, leave the catheter in the vagina as a landmark, indicating where not to insert, and insert another sterile catheter. Pulling the catheter back and reinserting is poor technique, increasing the risk for CAUTI.**
One lumen is for draining urine, one lumen to inflate the balloon: A. Single Lumen Catheter B. Double Lumen Catheter C. Triple Lumen Catheter
Double Lumen Catheter
What should a nurse try first when attempting to promote urination? Encourage fluids Restricting fluid intake to 1000 mL/day Administering medication before bed to stimulate voiding Having the patient lie down
Encourage fluids
ac
before meals
Which notations are not safe to use in medication administration process? q1d .5, 2.0 cc 0.5, 2 mL
q1d .5, 2.0 cc
qid
four times per day
tab
tablet
