Fundamentals Nurselabs Set #3

A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take each time he provides tracheostomy care? Select all that apply. A. Apply the oxygen source loosely if the SPO2 increases during the procedure. B. Use surgical asepsis to remove and clean the inner cannula. C. Clean the outer surfaces in a circular motion from the stoma site outward. D. Replace the tracheostomy ties with new ties. E. Cut a slit in gauze squares to place beneath the tube holder.

A, B, & C A tracheostomy is an opening (made by an incision) through the neck into the trachea (windpipe). A tracheostomy opens the airway and aids breathing. A tracheostomy may be required in an emergent setting to bypass an obstructed airway, or (more commonly) may be placed electively to facilitate mechanical ventilation, to wean from a ventilator, or to allow more efficient management of secretions (referred to as pulmonary toilet), among other reasons.

Nurse Stephanie is assessing a client who has an acute respiratory infection that puts her at risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxemia? Select all that apply. A. Restlessness B. Tachypnea C. Bradycardia D. Confusion E. Cyanosis

A, B, & E Restlessness, tachypnea, and pallor are early manifestations of hypoxemia, along with tachycardia, elevated blood pressure, use of accessory muscles, nasal flaring, tracheal tugging, and adventitious lung sounds. Bradycardia and confusion are late manifestations of hypoxemia, along with stupor, cyanotic skin and mucous membranes, bradypnea, hypotension, and cardiac dysrhythmias. Hypoxemia is defined as a decrease in the partial pressure of oxygen in the blood whereas hypoxia is defined by reduced level of tissue oxygenation. It can be due to either defective delivery or defective utilization of oxygen by the tissues. Option E: Cyanosis, a bluish color of skin and mucous membranes, indicates hypoxemia. Visible cyanosis typically is present when the concentration of deoxygenated hemoglobin in the capillaries of tissues is at least 5 g/dL.

During the assessment of the client with urinary incontinence, the nurse is most likely to assess for which of the following? Select all that apply. A. Perineal skin irritation B. Fluid intake of less than 1,500 mL/d C. History of antihistamine intake D. Hx of UTI E. A fecal impaction

A, B, D, and E Urinary incontinence is the involuntary leakage of urine. This medical condition is common in the elderly, especially in nursing homes, but it can affect younger adult males and females as well. Urinary incontinence can impact both patient health and quality of life. The prevalence may be underestimated as some patients do not inform health care providers of having issues with urinary incontinence for various reasons.

Which of the following is/are an example(s) of theoretical knowledge? Select all that apply. A. Antibiotics are ineffective in treating viral infections. B. When you take a patient's blood pressure, the patient's arm should be at heart level. C. In Maslow's framework, physical needs are most basic. D. When drawing medication out of a vial, inject air into the vial first. E. Let the patient dangle his feet first before assisting him to stand or transfer.

A, C Theoretical knowledge consists of research findings, facts (e.g., "Antibiotics are ineffective . . ." is a fact), principles, and theories (e.g., "In Maslow's framework . . ." is a statement from a theory). Instructions for taking blood pressure and withdrawing medications are examples of practical knowledge—what to do and how to do it. While practical knowledge is gained by doing things, theoretical knowledge is gained, for example, by reading a manual.

Which of the following is/are an example(s) of a health restoration activity? Select all that apply. A. Administering an antibiotic every day. B. Teaching the importance of handwashing. C. Assessing a client's surgical incision. D. Advising a woman to get an annual mammogram after age 50 years. E. Attending rehabilitation of a fractured arm.

A, C, E Health restoration activities help an ill client return to health. This would include taking an antibiotic every day and assessing a client's surgical incision. Hand washing and mammograms both involve healthy people who are trying to prevent illness.

Nurse Aldrin is preparing to perform endotracheal suctioning for a client. Which of the following are appropriate guidelines for the nurse to follow? Select all that apply. A. Apply suction while withdrawing the catheter. B. Perform suctioning on a routine basis, every 2 to 3 hours. C. Maintain medical asepsis during suctioning. D. Use a new catheter for each suctioning attempt. E. Limit suctioning to 2 to 3 attempts.

A, D, & E Within intensive care units (ICUs), one such common procedure is the suctioning of respiratory secretions in patients who have been intubated or who have undergone tracheostomy. The traditional goal of suctioning is to aid in maintaining airway patency and prevent complications related to the retention of secretions

A nurse educator on a medical unit is reviewing factors that increase the risk of urinary tract infections with a group of assistive personnel. Which of the following should be included in the review? Select all that apply. A. Having sexual intercourse on a frequent basis. B. Lowering of testosterone levels. C. Wiping from front to back. D. The location of the vagina in relation to the anus. E. Undergoing frequent catheterization.

A, D, and E Uncomplicated urinary tract infection (UTI) is a bacterial infection of the bladder and associated structures. These are patients with no structural abnormality and no comorbidities, such as diabetes, immunocompromised, or pregnancy. Uncomplicated UTI is also known as cystitis or lower UTI. E.coli causes the majority of UTI but other organisms of importance include proteus, klebsiella, and enterococcus. The diagnosis of UTI is made from the clinical history and urinalysis, but the proper collection of the urine sample is important.

1 cup is equal to how many ounces? A. 8 B. 80 C. 800 D. 8000

A. 8 One cup is equal to 8 ounces. Weight conversion is also utilized daily in health care. There are two systems calculating weight used in all healthcare settings for health management, such as medication dosing per patient body weight. First, the metric system is in common use in health care in the US. It is also the only system universally used in many countries on all continents of the globe. It has the advantage of a decimal system in increments or the power of tenths. Second, the US weight system customarily uses the ounce or pound. It derives from the British colonial era. This non-metric system is still being used nowadays among laypersons in the US for products sold to the public.

A client with a stage 2 pressure ulcer has methicillin-resistant Staphylococcus aureus (MRSA) cultured from the wound. Contact precautions are initiated. Which rule must be observed to follow contact precautions? A. A clean gown and gloves must be worn when in contact with the client. B. Everyone who enters the room must wear a N-95 respirator mask. C. All linen and trash must be marked as contaminated and send to biohazard waste. D. Place the client in a room with a client with an upper respiratory infection.

A. A clean gown and gloves must be worn when in contact with the client. A clean gown and gloves must be worn when any contact is anticipated with the client or with contaminated items in the room. Visitors might also be asked to wear a gown and gloves. Patients are asked to stay in their hospital rooms as much as possible. They should not go to common areas, such as the gift shop or cafeteria. They may go to other areas of the hospital for treatments and tests.

A client requires protective isolation. Which client can be safely paired with this client in a client-care assignment? One: A. Admitted with unstable diabetes mellitus. B. Who underwent surgical repair of a perforated bowel. C. With a stage 3 sacral pressure ulcer. D. Admitted with a urinary tract infection.

A. Admitted with unstable diabetes mellitus. The client with unstable diabetes mellitus can safely be paired in a client-care assignment because the client is free from infection. Protective Isolation aims to protect an immunocompromised patient who is at high risk of acquiring micro-organisms from either the environment or from other patients, staff, or visitors.

Nurse Peter makes the assessment that which client has the greatest risk for a problem with the transport of oxygen from the lungs to the tissues? A client who has: A. Anemia B. An infection C. A fractured rib D. A tumor of the medulla

A. Anemia Anemia is a condition of decreased red blood cells and decreased hemoglobin. Hemoglobin is how the oxygen molecules are transported to the tissues. Anemia is described as a reduction in the proportion of red blood cells. Anemia is not a diagnosis, but a presentation of an underlying condition. Whether or not a patient becomes symptomatic depends on the etiology of anemia, the acuity of onset, and the presence of other comorbidities, especially the presence of cardiovascular disease.

The nurse is working on a unit that uses nursing assessment flow sheets. Which statement best describes this form of charting? Nursing assessment flow sheets: A. Are comprehensive charting forms that integrate assessments and nursing actions. B. Contain only graphic information, such as I&O, vital signs, and medication administration. C. Are used to record routine aspects of care; they do not contain assessment data. D. Contain vital data collected upon admission, which can be compared with newly collected data.

A. Are comprehensive charting forms that integrate assessments and nursing actions Nursing assessment flow sheets are organized by body systems. The nurse checks the box corresponding to the current assessment findings. Nursing actions, such as wound care, treatments, or IV fluid administration, are also included. A flow sheet is simply a one- or two-page form that gathers all the important data regarding a patient's condition. The flow sheet is housed in the patient's chart and serves as a reminder of care and a record of whether care expectations have been met.

What should be done in order to prevent contaminating the environment in bed making? A. Avoid fanning soiled linens B. Strip all linens at the same time C. Finished both sides at the time D. Embrace soiled linen

A. Avoid fanning soiled linens Fanning soiled linens would scatter the lodged microorganisms and dead skin cells on the linens. Healthcare linens are known to harbor a number of microorganisms. Most notably, there is an increased concern that methicillin-resistant Staphylococcus aureus (MRSA)and vancomycin-resistant Enterococcus (VRE) can survive for days on linens. There is further concern that these contaminated linens then become a potential source of cross-contamination.

The charge nurse asks the nursing assistive personnel (NAP) to give a bag bath to a patient with end-stage chronic obstructive pulmonary disease. How should the NAP proceed? A. Bathe the patient's entire body using 8 to 10 washcloths. B. Assist the patient to a chair and provide bathing supplies. C. Saturate a towel and blanket in a plastic bag, and then bathe the patient. D. Assist the patient to the bathtub and provide a bath chair.

A. Bathe the patient's entire body using 8 to 10 washcloths. A towel bath is a modification of the bed bath in which the NAP places a large towel and a bath blanket into a plastic bag, saturates them with a commercially prepared mixture of moisturizer, non rinse cleaning agent, and water; warms in them in a microwave, and then uses them to bathe the patient. A bag bath is a modification of the towel bath, in which the NAP uses 8 to 10 washcloths instead of a towel or blanket. Each part of the patient's body is bathed with a fresh cloth.

Back Care is best described as: A. Caring for the back by means of massage. B. Washing of the back. C. Application of cold compress at the back. D. Application of hot compress at the back.

A. Caring for the back by means of massage Back care or massage is usually given in conjunction with the activities of bathing the client. It can also be done on other occasions when a client seems to have a risk of developing skin irritation due to bed rest. The goal when performing this procedure is to enhance relaxation, reduce muscle tension and stimulate circulation.

A client who has an indwelling catheter reports the need to urinate. Which of the following interventions should the nurse perform? A. Check to see whether the catheter is patent. B. Reassure the client that it is not possible for her to urinate. C. Re-catheterize the bladder with a larger gauge catheter. D. Collect a urine specimen for analysis.

A. Check to see whether the catheter is patent. A clogged or kinked catheter causes the bladder to fill and stimulates the need to urinate. An indwelling urinary catheter (IUC), generally referred to as a "Foley" catheter, is a closed sterile system with a catheter and retention balloon that is inserted either through the urethra or suprapubically to allow for bladder drainage. External collecting devices (e.g. drainage tubing and bag) are connected to the catheter for urine collection.

A provider prescribes a 24-hour urine collection for a client. Which of the following actions should the nurse take? A. Discard the first voiding. B. Keep all voidings in a container at room temperature. C. Ask the client to urinate and pour the urine into a specimen container. D. Ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container.

A. Discard the first voiding. The nurse should discard the first voiding of the 24 hour urine specimen, and note the time. 24-hour urine protein measures the amount of protein released in urine over a 24-hour period. The normal value is less than 100 milligrams per day or less than 10 milligrams per deciliter of urine.

Nurse Berta is facilitating a monthly mothers' class at a small village. As a knowledgeable nurse, she must know that a mother who breastfeeds her child passes on which antibody through breast milk? A. IgA B. IgE C. IgG D. IgM

A. IgA Antibodies, which are also called immunoglobulins, take five basic forms, indicated as IgG, IgA, IgM, IgD and IgE. All have been detected in human milk, but by far the most abundant type is IgA, particularly the form known as secretory IgA, which is found in great amounts throughout the gut and respiratory system of adults. The secretory IgA molecules passed to the suckling child are helpful in ways that go beyond their ability to bind to microorganisms and keep them away from the body's tissues.

The catheter slips into the vagina during a straight catheterization of a female client. The nurse does which action? A. Leaves the catheter in place and gets a new sterile catheter. B. Leaves the catheter in place and asks another nurse to attempt the procedure. C. Removes the catheter and redirects it to the urinary meatus. D. Removes the catheter, wipes it with a sterile gauze, and redirects it to the urinary meatus.

A. Leaves the catheter in place and gets a new sterile catheter. The catheter in the vagina is contaminated and can't be reused. If left in place, it may help avoid mistaking the vaginal opening for the urinary meatus. A single failure to catheterize the meatus doesn't indicate that another nurse is needed although sometimes a second nurse can assist in visualization of the meatus. Urinary bladder catheterization is performed for both therapeutic and diagnostic purposes. Based on the dwell time, the urinary catheter can be either intermittent (short-term) or indwelling (long-term).

Nurse Aleli is planning to perform percussion and postural drainage. Which is an important aspect of planning the clients' care? A. Percussion and postural drainage should be done before lunch. B. The order should be coughing, percussion, positioning, and then suctioning. C. A good time to perform percussion and postural drainage is in the morning after breakfast when the client is well rested. D. Percussion and postural drainage should always be preceded by three minutes of 100% oxygen.

A. Percussion and postural drainage should be done before lunch. Postural drainage results in expectoration of large amounts of mucus. Clients sometimes ingest part of the secretions. The secretions may also produce an unpleasant taste in the oral cavity, which could result in nausea/vomiting. This procedure should be done on an empty stomach to decrease client discomfort.

The nurse is orienting a new nurse to the unit and reviews source-oriented charting. Which statement by the nurse best describes source-oriented charting? Source-oriented charting: A. Separates the health record according to discipline. B. Organizes documentation around the patient's problems. C. Highlights the patient's concerns, problems, and strengths. D. Is designed to streamline documentation.

A. Separates the health record according to discipline In source-oriented charting, each discipline documents findings in a separately labeled section of the chart. Source-oriented (SO) charting is a narrative recording by each member (source) of the health care team charts on separate records. SO charting is time-consuming and can lead to fragmented care. Effective documentation requires the use of common vocabulary; legibility and neatness; the use of only authorized abbreviations and symbols; factual and time-sequenced organization; and accuracy, including any errors that occurred. All documents related to client care are confidential and clients must sign a release to have their information released, specifying what type of information may be released and to whom it may be released.

The nurse administers a cleansing enema. The common position for this procedure is? A. Sims left lateral B. Dorsal Recumbent C. Supine D. Prone

A. Sims left lateral This position provides comfort to the patient and easy access to the natural curvature of the rectum. Enemas are rectal injections of fluid intended to cleanse or stimulate the emptying of the bowel. Enemas may also be prescribed to flush out the colon before certain diagnostic tests or surgeries. The bowel needs to be empty before these procedures to reduce infection risk and prevent stool from getting in the way.

Nurse Trixie is preparing to perform tracheostomy care. Prior to the beginning of the procedure, the nurse performs which action? A. Tells the client to raise two fingers to indicate pain or distress. B. Changes twill tape holding the tracheostomy and place. C. Cleans the incision site. D. Check the tightness of the ties and knot.

A. Tells the client to raise two fingers to indicate pain or distress. Prior to starting the procedure, it is important to develop a means of communication by which the client can express pain or discomfort. Tracheostomy is a procedure where an artificial airway is established surgically or percutaneously in the cervical trachea. The term "tracheostomy" has evolved to refer to both the procedure as well as the clinical condition of having a tracheostomy tube. With the increasing number of patients with tracheostomy, safe caring requires knowledge and competencies in dealing with routine care, weaning, decannulation, as well as tracheostomy-related emergencies.

The nurse is ordered to administer ampicillin capsule TID p.o. The nurse should give the medication by which frequency? A. Three times a day orally B. Three times a day after meals C. Two times a day by mouth D. Two times a day before meals

A. Three times a day orally TID is the Latin for "ter in die" which means three times a day. P.O. means per orem or through mouth. The "time" of administration of medication is valuable information to consider during patient counselling and is a typical query by patients especially when filling a prescription for the first time.

The most important purpose of cleansing bed bath is: A. To cleanse, refresh and give comfort to the client who must remain in bed. B. To expose the necessary parts of the body. C. To develop skills in bed bath. D. To check the body temperature of the client in bed.

A. To cleanse, refresh and give comfort to the client who must remain in bed. The nurse provides a bed bath for patients who must remain in bed and depend on someone else for their care. It is an important part of the patient's daily care. Not only does it remove sweat, oil, and micro-organisms from the patient's skin, but it also stimulates circulation and promotes a feeling of self-worth by improving the patient's appearance. For patients who are on bedrest, bathing can also be a time for socialization.

The clinical instructor asks her students the rationale for handwashing. The students are correct if they answered that handwashing is expected to remove: A. Transient flora from the skin B. Resident flora from the skin C. All microorganisms from the skin D. Media for bacterial growth

A. Transient flora from the skin There are two types of normal flora: transient and resident. Transient flora are normal flora that a person picks up by coming in contact with objects or another person (e.g., when you touch a soiled dressing). You can remove these with hand washing. Hand washing can prevent about 30% of diarrhea-related illnesses and about 20% of respiratory infections (e.g., colds). Antibiotics often are prescribed unnecessarily for these health issues

A practitioner uses a urine specimen for culture and sensitivity via a straight catheter for a patient. What should the nurse do when collecting this urine specimen? A. Use a sterile specimen container. B. Collect urine from the catheter port. C. Inflate the balloon with 10 mL of sterile water. D. Have the patient void before collecting the specimen.

A. Use a sterile specimen container. A culture attempts to identify the microorganisms present in the urine, and a sensitivity study identifies the antibiotics that are effective against the isolated microorganisms. A sterile specimen container is used to prevent contamination of the specimen by microorganisms outside the body (exogenous). B. This is a straight catheter so it doesn't have a catheter port.

A nurse in a provider's office is assessing a client who reports losing control of urine whenever she coughs, laughs, or sneezes. The client relates a history of three vaginal births, but no serious accidents or illnesses. Which of the following interventions are appropriate for helping to control or eliminate the clients incontinence? Select all that apply. A. Limit total daily fluid intake B. Decrease or avoid caffeine C. Increase the intake of calcium supplements D. Avoid the intake of alcohol E. Use Crede maneuver

B and D Caffeine and alcohol are bladder irritants and can worsen stress incontinence. Alcohol is a bladder irritant and can worsen stress incontinence. Quitting smoking, losing excess weight, or treating a chronic cough will lessen the risk of stress incontinence and improve the symptoms. Stress incontinence is different from urgency incontinence and overactive bladder (OAB). If the client has urgency incontinence or OAB, the bladder muscle contracts, causing a sudden urge to urinate before he can get to the bathroom. Stress incontinence is much more common in women than in men.

A nurse is preparing to initiate a bladder training program for a client who has a voiding disorder. Which of the following actions should the nurse take? Select all that apply. A. Establish a schedule of voiding prior to meal times. B. Have the client record voiding times. C. Gradually increase the voiding intervals. D. Reminded client to hold urine until next scheduled voiding time. E. Provide a sterile container for voiding.

B, C, and D Ask the client to keep track of voiding times is an appropriate nursing action. Gradually increasing the voiding interval is an appropriate nursing action. The client should be reminded to hold urine until the next scheduled voiding time. Bladder training involves voiding at scheduled in frequent intervals and gradually increasing these intervals to four hours.

A female client has a urinary tract infection. Which teaching points by the nurse should be helpful to the client? Select all that apply. A. Limit fluids to avoid the burning sensation on urination. B. Review symptoms of UTI with the client. C. Wipe the perineal area from back to front. D. Wear cotton underclothes. E. Take baths rather than showers.

B, D Uncomplicated urinary tract infection (UTI) is a bacterial infection of the bladder and associated structures. These are patients with no structural abnormality and no comorbidities, such as diabetes, immunocompromised, or pregnant. Uncomplicated UTI is also known as cystitis or lower UTI. Forty percent of women in the United States will develop a UTI during their lifetime, making it one of the most common infections in women. UTI is uncommon in circumcised males, and by definition, any male UTI is considered complicated.

Which of the following behaviors indicates that the client on a bladder training program has met the expected outcomes? Select all that apply. A. Voids each time there is an urge. B. Practices slow, deep breathing until the urge decreases. C. Uses adult diapers, for "just in case". D. Drinks citrus juices and carbonated beverages. E. Performs pelvic muscle exercises.

B, E It is important for the client to inhibit the urge to void sensation when a premature urge is experienced. Bladder training, a program of urinating on schedule, enables the client to gradually increase the amount of urine the client can comfortably hold. Bladder training is a mainstay of treatment for urinary frequency and overactive bladder in both women and men, alone or in conjunction with medications or other techniques.

Which client statement informs the nurse that his teaching about the proper use of an incentive spirometer was effective? A. "I should breathe out as fast and as hard as possible into the device." B. "I should inhale slowly and steadily to keep the balls up." C. "I should use the device three times a day, after meals." D. "The entire device should be washed thoroughly in sudsy water once a week."

B. "I should inhale slowly and steadily to keep the balls up." Proper use of an SMI requires the client to take slow, steady inhalations, every hour or two, 5 to 10 reps each time. Spirometry is one of the most readily available and useful tests for pulmonary function. It measures the volume of air exhaled at specific time points during complete exhalation by force, which is preceded by a maximal inhalation. The most important variables reported include total exhaled volume, known as the forced vital capacity (FVC), the volume exhaled in the first second, known as the forced expiratory volume in one second (FEV1), and their ratio (FEV1/FVC).

20 cc is equal to how many ml? A. 2 B. 20 C. 2000 D. 20000

B. 20 One cubic centimeter is equal to one milliliter. When clinicians are prepared and know the key conversion factors, they will be less anxious about the calculation involved. This is vital to accuracy, regardless of which formula or method employed.

One (1) tsp is equal to how many drops? A. 15 B. 60 C. 10 D. 30

B. 60 One teaspoon (tsp) is equal to 60 drops (gtts). When the nurse has an order for an IV infusion, it is her responsibility to make sure the fluid will infuse at the prescribed rate. IV fluids may be infused by gravity using a manual roller clamp or dial-a-flow, or infused using an infusion pump. Regardless of the method, it is important to know how to calculate the correct IV flow rate.

Nurse CJ is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority? A. Increase the oxygen flow. B. Assist the client with Fowler's position. C. Promote removal of pulmonary secretions. D. Attain a specimen for arterial blood gases.

B. Assist the client with Fowler's position. The priority action the nurse should take when using the airway, breathing, circulation approach to care delivery is to relieve the clients' dyspnea. Fowler's position facilitates maximal long expansion and thus optimizing breathing. With the client in this position, the nurse can better assess and determine the cause of the clients dyspnea.

It refers to the preparation of the bed with a new set of linens A. Bed bath B. Bed making C. Bed shampoo D. Bed lining

B. Bed making Bed making is one of the important nursing techniques to prepare various types of bed for patients or clients to guarantee comfort and beneficial position for a specific condition. The bed is particularly important for patients who are sick. The nurse plays an inevitable role to ensure comfort and cleanliness for ill patients. It should be adaptable to various positions as per patient's needs because they spend a varying amount of the day in bed.

The nurse prepares to administer buccal medication. The medicine should be placed in what area? A. On the client's skin. B. Between the client's cheeks and gums. C. Under the client's tongue. D. On the client's conjunctiva.

B. Between the client's cheeks and gums Buccal administration involves placing a drug between the gums and cheek, where it also dissolves and is absorbed into the blood. Because the medication absorbs quickly, these types of administration can be important during emergencies when you need the drug to work right away, such as during a heart attack.

The nurse must verify the client's identity before administration of medication. Which of the following is the safest way to identify the client? A. Ask the client his name. B. Check the client's identification band. C. State the client's name aloud and have the client repeat it. D. Check the room number.

B. Check the client's identification band The identification band is the safest way to know the identity of a patient whether he is conscious or unconscious. Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed before administration.

Which action represents the appropriate nursing management of a client wearing a condom catheter? A. Ensure that the tip of the penis fits snugly against the end of the condom. B. Check the penis for adequate circulation 30 min after applying. C. Change the condom every 8 hours. D. Tape the collecting tube to the lower abdomen.

B. Check the penis for adequate circulation 30 min after applying The penis and condom should be checked 1/2 hour after application to ensure that it's not too tight. and the tubing is taped to the leg or attached to a leg bag. Condom catheters are external urinary catheters that are worn like a condom. They collect urine as it drains out of your bladder and send it to a collection bag strapped to your leg. They're typically used by men who have urinary incontinence (can't control their bladder).

What should Nurse Mavie do first if a patient is choking on food? A. Apply sharp for thrusts over the patient's xiphoid process. B. Determine if the patient can make any verbal sounds. C. Hit the middle of the patients back firmly. D. Sweep the patient's mouth with a finger.

B. Determine if the patient can make any verbal sounds. When a person is choking on food, the first intervention is to determine if the person can speak because the next intervention will depend on if it is partial or total airway obstruction. With a partial airway obstruction, the person will be able to make sounds because some air can pass from the lungs through the vocal cords. In this situation the person's own efforts open parentheses gagging and coughing) should be allowed to clear the airway. With a total airway obstruction, the person will not be able to make a sound because the airway is blocked and the nurse should immediately initiate the abdominal thrust maneuver (Heimlich maneuver).

A nurse must measure the intake and output (I&O) for a patient who has a urinary retention catheter. Which equipment is most appropriate to use to accurately measure urine output from a urinary retention catheter? A. Urinal B. Graduate C. Large syringe D. Urine collection bag

B. Graduate A graduate is a collection container with volume markings usually at 25 mL increments that promote accurate measurements of urine volume. To measure urine output in critical care units, a Foley catheter is introduced through the patient's urethra until it reaches his/her bladder. The other end of the catheter is connected to a graduated container that collects the urine.

Nurse Sue teaches a patient about pursed lip breathing. The nurse identifies that the teaching is affected when the patient says its purpose is to: A. Precipitate coughing B. Help maintain open airways C. Decrease intrathoracic pressure D. Facilitate expectoration of mucus

B. Help maintain open airways Pursed-lip breathing involves deep inspiration and prolonged expiration against slightly closed lips. The pursed lips create a resistance to the air flowing out of the lungs, which prolongs exhalation and maintains positive airway pressure, thereby maintaining an open airway and preventing airway collapse. Pursed lip breathing is beneficial for people with chronic lung disease. It can help strengthen the lungs and make them more efficient.

Nurse Winona teaches a patient how to use an incentive spirometer. What patient outcome will support the conclusion that the use of the incentives spirometer was effective? A. Supplemental oxygen use will be reduced. B. Inspiratory volume will be increased. C. Sputum will be expectorated. D. Coughing will be stimulated.

B. Inspiratory volume will be increased. An incentive spirometry or provides a visual goal for and measurement of inspiration. It encourages the patient to execute and maintain a sustained inspiration. A sustained inspiration opens airways, increases the inspiratory volume, and reduces the risk of atelectasis. Spirometry is one of the most readily available and useful tests for pulmonary function. It measures the volume of air exhaled at specific time points during complete exhalation by force, which is preceded by a maximal inhalation.

A client exhibits all of the following during a physical assessment. Which of these is considered a primary defense against infection? A. Fever B. Intact skin C. Inflammation D. Lethargy

B. Intact skin Intact skin is considered a primary defense against infection. Usually, the skin prevents invasion by microorganisms unless it is damaged (for example, by an injury, insect bite, or burn). Mucous membranes, such as the lining of the mouth, nose, and eyelids, are also effective barriers. Typically, mucous membranes are coated with secretions that fight microorganisms. For example, the mucous membranes of the eyes are bathed in tears, which contain an enzyme called lysozyme that attacks bacteria and helps protect the eyes from infection. Fever, the inflammatory response, and phagocytosis (a process of killing pathogens) are considered secondary defenses against infection.

The nurse will need to assess the client's performance of clean intermittent self catheterization (CISC) for a client with which urinary diversion? A. Ileal conduit B. Kock pouch C. Neobladder D. Vesicostomy

B. Kock pouch The ileal conduit and vesicostomy are incontinent urinary diversions, and clients are required to use an external ostomy appliance to contain the urine. In this new operation, a pouch or reservoir is fashioned out of the terminal ileum with a valve mechanism at its exit to the skin surface. This allows storage of the liquid bowel contents in an expandable container with no leakage of stool or gas and therefore no skin problems. There is no need for appliances or bags, no embarrassment from the involuntary noise and smell of flatus through the ileostomy. The stoma is created flush and within the bikini line. The patient catheterizes the pouch on an average of three times a day.

A practitioner orders chest physiotherapy with percussion and vibration for a newly admitted patient. Which information obtained by the nurse during the health history should alert the nurse to question the practitioner's order? A. Emphysema B. Osteoporosis C. Cystic fibrosis D. Chronic bronchitis

B. Osteoporosis Implementing the practitioner's order may compromise patient safety because percussion and vibration in the presence of osteoporosis may cause fractures. Osteoporosis is an abnormal loss of bone mass and strength. Chest physiotherapy is a group of physical techniques that improve lung function and help you breathe better. Chest PT, or CPT expands the lungs, strengthens breathing muscles, and loosens and improves drainage of thick lung secretions.

Which of the following incidents requires the nurse to complete an occurrence report? A. Medication given 30 minutes after scheduled dose time. B. Patient's dentures lost after transfer. C. Worn electrical cord discovered on an IV infusion pump. D. Prescription without the route of administration.

B. Patient's dentures lost after transfer You would need to complete an occurrence report if you suspect your patient's personal items to be lost or stolen. An incident report also provides vital information the facility needs to decide whether restitution should be made—if personal belongings were lost or damaged, for example. Without proper documentation of the incident, there's no way to make these important decisions effectively.

While a client with chest tubes is ambulating, the connection between the tube and the water seal dislodges. Which action by Nurse Flora is most appropriate? A. Assist the client to ambulate back to bed. B. Reconnect the tube to the water seal. C. Assess the client's lung sounds with a stethoscope. D. Have the client cough forcibly several times.

B. Reconnect the tube to the water seal. The tube should be reconnected to the water seal as quickly as possible. Assisting the client back to bed and assessing the client's lung are possible actions after the system is reconnected. Or place the end of the tube in a bottle of sterile water, creating a water seal. Instruct a colleague to prepare a new sterile chest-drainage collection device, or retrieve a new sterile connector while safely returning the patient to bed. Observe the patient for signs and symptoms of respiratory decline. Then reconnect the chest tube to the new drain and unclamp it.

A man brings his elderly wife to the emergency department. He states that she has been vomiting and has had diarrhea for the past two days. She appears lethargic and is complaining of leg cramps. What should the nurse do first? A. Start an IV. B. Review the results of serum electrolytes. C. Offer the woman foods that are high in sodium and potassium content. D. Administer an antiemetic.

B. Review the results of serum electrolytes. Further assessment is needed to determine appropriate action. While the nurse may perform some of the interventions in options one, three, and four, assessment is needed initially. Electrolyte abnormalities may be addressed on an individual level, although often these are caused by an overall fluid volume depletion which, when corrected, will also cause electrolytes to normalize. Both saline and lactated Ringer's solutions appear to be effective for the treatment of dehydration due to viral gastroenteritis.

Which of the following is the most important purpose of handwashing? A. To promote hand circulation. B. To prevent the transfer of microorganisms. C. To avoid touching the client with a dirty hand. D. To provide comfort.

B. To prevent the transfer of microorganism Hand washing is the single most effective infection control measure. Handwashing practices in the patient care setting began in the early 19th century. The practice evolved over the years with evidential proof of its vast importance and coupled with other hand-hygienic practices, decreased pathogens responsible for nosocomial or hospital-acquired infections (HAI).

A patient's urine is cloudy, is amber, and has an unpleasant odor. What problem may this information indicate that requires the nurse to make a focused assessment? A. Urinary retention B. Urinary tract infection C. Ketone bodies in the urine D. High urinary calcium level

B. Urinary tract infection The urine appears concentrated (amber)and cloudy because of the presence of bacteria, white blood cells, and red blood cells. The unpleasant odor is caused by pus in the urine (pyuria). Uncomplicated urinary tract infection (UTI) is a bacterial infection of the bladder and associated structures. These are patients with no structural abnormality and no comorbidities, such as diabetes, immunocompromised, or pregnancy. Uncomplicated UTI is also known as cystitis or lower UTI.

An elderly nursing home resident has refused to eat or drink for several days and is admitted to the hospital. The nurse should expect which assessment finding? A. Increase blood pressure B. Weak, rapid pulse C. Moist mucous membranes D. Jugular vein distention

B. Week, rapid pulse All other options are indicated by fluid volume excess. A client who has not eaten or drunk anything for several days would be experiencing a fluid volume deficit. The primary control of water homeostasis is through osmoreceptors in the brain. Dehydration, as perceived by these osmoreceptors, stimulates the thirst center in the hypothalamus, which leads to water consumption. These osmoreceptors can also cause conservation of water by the kidney. When the hypothalamus detects lower water concentration, it causes the posterior pituitary to release antidiuretic hormone (ADH), which stimulates the kidneys to reabsorb more water.

Which statement indicates a need for further teaching of a home care client with a long term indwelling catheter? A. "I will keep the collecting bag below the level of the bladder at all times." B. "Intake of cranberry juice may help decrease the risk of infection." C. "Soaking in a warm tub bath may ease the irritation associated with the catheter." D. "I should use clean tech. when emptying the collecting bag."

C. "Soaking in a warm tub bath may ease the irritation associated with the catheter" Soaking in a bathtub can increase the risk of exposure to bacteria. Avoid taking baths, but shower daily. For the first few days after getting a suprapubic catheter, use a waterproof bandage when showering. Once the wound heals, the client can shower as usual, but avoid scented soaps.

A client complains of difficulty swallowing when the nurse tries to administer capsule medication. Which of the following measures should the nurse do? A. Dissolve the capsule in a glass of water. B. Break the capsule and give the content with applesauce. C. Check the availability of a liquid preparation. D. Crush the capsule and place it under the tongue.

C. Check the availability of a liquid preparation. The nurse should check first if the medication is available in liquid form before doing Choice A. The swallowing of capsules can be particularly difficult. This is because capsules are lighter than water and float due to air trapped inside the gelatine shell. In comparison, tablets are heavier than water and do not float.

Which of the following is the appropriate meaning of CBR? A. Cardiac Board Room B. Complete Bathroom C. Complete Bed Rest D. Complete Board Room

C. Complete Bed Rest CBR means complete bed rest. For more abbreviations, please see this post. Standardization and uniform use of codes, symbols, and abbreviations can improve communication and understanding between health care practitioners, leading to safer and more effective care for patients.

Which focus is the nurse most likely to teach for a client with a flaccid bladder? A. Habit training: attempt voiding at specific time periods. B. Bladder training: delay voiding according to a pre-schedule timetable. C. Crede's maneuver: apply gentle manual pressure to the lower abdomen. D. Kegel exercises: contract the pelvic muscles.

C. Crede's maneuver: apply gentle manual pressure to the lower abdomen. Because the bladder muscles will not contract to increase the intra-bladder pressure to promote urination, the process is initiated manually. The Credé maneuver is a technique used to void urine from the bladder of an individual who, due to disease, cannot do so without aid. The Credé maneuver is executed by exerting manual pressure on the abdomen at the location of the bladder, just below the navel. Options one, two, and four: to promote continence bladder contractions are required for habit training, bladder training, and increasing the tone of the pelvic muscles.

The charge nurse on the medical-surgical floor assigns vital signs to the nursing assistive personnel (NAP) and medication administration to the licensed vocational nurse (LVN). Which nursing model of care is this floor following? A. Team nursing B. Case method nursing C. Functional nursing D. Primary nursing

C. Functional nursing This medical-surgical floor is following the functional nursing model of care, in which care is partitioned and assigned to a staff member with the appropriate skills. For example, the NAP is assigned vital signs, and the LVN is assigned medication administration. Functional nursing is task-oriented in scope. Instead of one nurse performing many functions, several nurses are given one or two assignments. For example, there is a medicine nurse whose sole responsibility is administering medications.

To prevent postoperative complications, Nurse Kim assists the client with coughing and deep breathing exercises. This is best accomplished by implementing which of the following? A. Coughing exercises one hour before meals and deep breathing one hour after meals. B. Forceful coughing as many times as tolerated. C. Huff coughing every two hours or as needed. D. Diaphragmatic and pursed lip breathing 5 to 10 times, four times a day.

C. Huff coughing every two hours or as needed. Huff coughing helps keep the airways open and secretions mobilized. Huff coughing is an alternative for clients who are unable to perform a normal forceful cough (such as postoperatively) deep breathing and coughing should be performed at the same time. Option D: Diaphragmatic and pursed-lip breathing are techniques used for clients with obstructive airway disease. You can perform breathing exercises by relaxing your shoulders and upper chest. Take a deep breath in through your nose. Hold the breath for three seconds. Breathe out slowly through your mouth. Repeat three times. Taking too many breaths can make you dizzy or light-headed. Perform breathing exercises every hour.

Nurse AJ is applying a warm compress. What should the nurse explain to the patient is the primary reason why heat is used instead of cold? A. Minimizes muscle spasms B. Prevents hemorrhage C. Increases circulation D. Reduces discomfort

C. Increases circulation Heat increases the skin surface temperature, promoting vasodilation, which increases blood flow to the area. Cold has the opposite effect: it promotes vasoconstriction, which decreases blood flow to the area. In general, heat therapy is also recommended prior to exercise for those who have chronic injuries. Heat warms the muscles and helps increase flexibility. The only time one should ever consider using cold to treat a chronic injury is after finishing exercising when inflammation may reappear. Applying cold at this time helps reduce any residual swelling.

Patient Z asks Nurse Toni why an electronic health record (EHR) system is being used. Which response by the nurse indicates an understanding of the rationale for an EHR system? A. It includes organizational reports of unusual occurrences that are not part of the client's record. B. This type of system consists of combined documentation and daily care plans. C. It improves interdisciplinary collaboration that improves efficiency in procedures. D. This type of system tracks medication administration and usage over 24 hours.

C. It improves interdisciplinary collaboration that improves efficiency in procedures. The EHR has several benefits for users, including improving interdisciplinary collaboration and making procedures more accurate and efficient. An Electronic Health Record (EHR) is an electronic version of a patient's medical history, that is maintained by the provider over time, and may include all of the key administrative clinical data relevant to that persons care under a particular provider, including demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, and radiology reports The EHR automates access to information and has the potential to streamline the clinician's workflow. The EHR also has the ability to support other care-related activities directly or indirectly through various interfaces, including evidence-based decision support, quality management, and outcomes reporting.

When the nurse completes the patient's admission nursing database, the patient reports that he does not have any allergies. Which acceptable medical abbreviation can the nurse use to document this finding? A. NA B. NDA C. NKA D. NPO

C. NKA The nurse can use the medical abbreviation NKA, which means no known allergies, to document this finding. NKA is the abbreviation for "no known allergies," meaning no known allergies of any sort. By contrast, NKDA stands exclusively for "no known drug allergies."

Which term does the nurse document to best describe a client experiencing shortness of breath while lying down who must assume an upright or sitting position to breathe more comfortably and effectively? A. Dyspnea B. Hyperpnea C. Orthopnea D. Apnea

C. Orthopnea Respiratory difficulty related to a reclining position without other physical alterations is defined as orthopnea. Orthopnea is the sensation of breathlessness in the recumbent position, relieved by sitting or standing. Orthopnea is caused by pulmonary congestion during recumbency. In the horizontal position there is redistribution of blood volume from the lower extremities and splanchnic beds to the lungs.

A nurse is caring for a debilitated female patient with nocturia. Which nursing intervention is the priority when planning to meet this patient's needs? A. Encouraging the use of bladder training exercises. B. Providing assistance with toileting every four hours. C. Positioning a bedside commode near the bed. D. Teaching the avoidance of fluid after 5 PM.

C. Positioning a bedside commode near the bed. The use of a commode requires less energy than using a bedpan and is safer than walking to the bathroom. Sitting on the commode uses gravity to empty the bladder fully and thus prevent urinary stasis. Nocturia is defined as the need for a patient to get up at night on a regular basis to urinate. A period of sleep must precede and follow the urinary episode to count as a nocturnal void. This means the first-morning void is not considered when determining nocturia episodes. Use of a bedside commode or urinal can minimize the bother, if not the frequency, of nocturia and may reduce the risk of falls. Remove any obstacles, loose rugs, or furniture between the bed and the nearest commode to reduce fall risk further. Consider using nightlights to help illuminate the passage to the bathroom.

Which of the following aspects of nursing is essential to defining it as both a profession and a discipline? A. Established standards of care B. Professional organizations C. Practice supported by scientific research D. Activities determined by a scope of practice

C. Practice supported by scientific research A profession must have knowledge that is based on technical and scientific knowledge. The theoretical knowledge of a discipline must be based on research, so both are scientifically based. The profession of nursing consists of persons educated in the discipline according to nationally regulated, defined, and monitored standards. The standards and regulations are to preserve healthcare safety for members of society. Although the discipline and the profession of nursing have different goals, the raison d'être of nursing is the enhancement of quality of life for humankind. The discipline provides the science lived in the art of practice.

A nurse has identified that the patient has overflow incontinence. What is a major factor that contributes to this clinical manifestation? A. Coughing B. Mobility deficits C. Prostate enlargement D. Urinary tract infection

C. Prostate enlargement An enlarged prostate compresses the urethra and interferes with the outflow of urine, resulting in urinary retention. With urinary retention, the pressure within the bladder builds until the external urethral sphincter temporarily opens to allow a small volume (25-60mL) of urine to escape (overflow incontinence). Men who are unable to completely empty their bladder and experience unexpected urine leakage may have what is called overflow incontinence. D. Urinary tract infection- Urge incontinence

Which action by the nurse represents proper nasopharyngeal/nasotracheal suctioning technique? A. Lubricate the suction catheter with petroleum jelly before and between insertion. B. Apply suction intermittently while inserting the suction catheter. C. Rotate the catheter while applying suction. D. Hyper oxygenate with 100% oxygen for 30 minutes before and after suctioning.

C. Rotate the catheter while applying suction. Rotating the catheter prevents pulling of tissue into the opening on the catheter tip and the side. Suction is used to clear retained or excessive lower respiratory tract secretions in patients who are unable to do so effectively for themselves. This could be due to the presence of an artificial airway, such as an endotracheal or tracheostomy tube, or in patients who have a poor cough due to an array of reasons such as excessive sedation or neurological involvement.

For a morbidly obese patient, which intervention should the nurse choose to counteract the pressure created by the skin folds? A. Cover the mattress with a sheepskin. B. Keep the linens wrinkle free. C. Separate the skin folds with towels. D. Apply petrolatum barrier creams.

C. Separate the skin folds with towels. Separating the skin folds with towels relieves the pressure of skin rubbing on skin. Skin folds, in particular, may be difficult for the patient to clean thoroughly; the abdominal folds and groins may be ignored, leading to an increased risk of skin breakdown in these areas.

Which of the following is the appropriate route of administration for insulin? A. Intramuscular B. Intradermal C. Subcutaneous D. Intravenous

C. Subcutaneous The subcutaneous tissue of the abdomen is preferred because the absorption of the insulin is more consistent from this location than subcutaneous tissues in other locations. Insulin may be injected into the subcutaneous tissue of the upper arm and the anterior and lateral aspects of the thigh, buttocks, and abdomen (with the exception of a circle with a 2-inch radius around the navel).

A client with emphysema is prescribed corticosteroid therapy on a short-term basis for acute bronchitis. The client asks the nurse how the steroids will help him. The nurse responded by saying that the corticosteroids will do which of the following? A. Promote bronchodilation B. Help the client to cough C. Prevent respiratory infection D. Decrease inflammation in the airways

D. Decrease inflammation in the airways Glucocorticoids are prescribed because of their anti-inflammatory effect. Options 1, 2, and 4 are not achieved with glucocorticoids. Corticosteroids produce their effect through multiple pathways. In general, they produce anti-inflammatory and immunosuppressive effects, protein and carbohydrate metabolic effects, water and electrolyte effects, central nervous system effects, and blood cell effects.

At the end of the shift, the nurse realizes that she forgot to document a dressing change that she performed for a patient. Which action should the nurse take? A. Complete an occurrence report before leaving. B. Do nothing; the next nurse will document it was done. C. Write the note of the dressing change into an earlier note. D. Make a late entry as an addition to the narrative notes.

D. Make a late entry as an addition to the narrative notes. If the nurse fails to make an important entry while charting, she should make a late entry as an addition to the narrative notes. The nurse can only document care directly performed or observed. Therefore, the nurse on the incoming shift would not record the wound change as performed. A primary purpose of documentation and recordkeeping systems is to facilitate information flow that supports the continuity, quality, and safety of care.

A newly hired at Nurseslabs Medical Center is assigned to the OR Department. Which action demonstrates a break in sterile technique? A. Remaining 1 foot away from non sterile areas. B. Placing sterile items on the sterile field. C. Avoiding the border of the sterile drape. D. Reaching 1 foot over the sterile field.

D. Reaching 1 foot over the sterile field. Reaching over the sterile field while wearing sterile garb breaks the sterile technique. While observing sterile technique, healthcare workers should remain 1 foot away from non-sterile areas while wearing sterile garb, place sterile items needed for the procedure on the sterile drape, and avoid coming in contact with the 1-inch border of the sterile drape. The principles of the Sterile Technique are applied in various ways. If the principle itself is understood, the applications of it become obvious. A strict aseptic technique is needed at all times in the Operating Room.

In the United States, the first programs for training nurses were affiliated with: A. The military B. General hospitals C. Civil service D. Religious orders

D. Religious orders When the Civil War broke out, the Army used nurses who had already been trained in religious orders. Nursing started with religious orders. The Hindu faith was the first to write about nursing. In the United States, all training for nurses was affiliated with religious orders until after the Civil War.

Paul Jake suffered a stroke and has difficulty swallowing. Which healthcare team member should be consulted to assess the patient's risk for aspiration? A. Respiratory therapist B. Occupational therapist C. Dentist D. Speech therapist

D. Speech therapist Speech and language therapists provide assistance to clients experiencing swallowing and speech disturbances. They assess the risk for aspiration and recommend a treatment plan to reduce the risk. Speech-language pathologists (SLPs) work to prevent, assess, diagnose, and treat speech, language, social communication, cognitive-communication, and swallowing disorders in children and adults.

The nurse recognizes that urinary elimination changes may occur even in healthy older adults because of which of the following? A. The bladder distends and its capacity increases. B. Older adults ignore the need to void. C. Urine becomes more concentrated. D. The amount of urine retained after voiding increases.

D. The amount of urine retained after voiding increases The capacity of the bladder may decrease with age but the muscle is weaker and can cause urine to be retained. Muscle changes and changes in the reproductive system can affect bladder control. As the volume of urine held by the bladder increases, so too does the pressure therein. Wall pressure of 5 to 15 mm Hg creates a sensation of bladder fullness while 30 mm Hg and beyond is painful. The sensation of increasing bladder fullness is conveyed to the spinal cord via the pudendal and hypogastric nerves on both A-delta and C nerve fibers.

During shift report, the nurse learns that an older female client is unable to maintain continence after she senses the urge to void and becomes incontinent on the way to the bathroom. Which nursing diagnosis is most appropriate? A. Stress urinary incontinence B. Reflex urinary incontinence C. Functional urinary incontinence D. Urge urinary incontinence

D. Urge urinary incontinence The key phrase is "the urge to void" option one occurs when the client coughs, sneezes, or jars the body, resulting in accidental loss of urine. If one feels a strong urge to urinate even when the bladder isn't full, the incontinence might be related to overactive bladder, sometimes called urge incontinence. This condition occurs in both men and women and involves an overwhelming urge to urinate immediately, frequently followed by loss of urine before the client can reach a bathroom. Even if one never has an accident, urgency and urinary frequency can interfere with work and a social life because of the need to keep running to the bathroom.