Interventions 2 Exam 1 Modules 1-5
The nurse is applying a saline-moistened dressing to a client's wound. The client asks, "Wouldn't it be better to let my wound dry out so a scab can form?" Which response is most appropriate?
"Wounds heal better when a moist wound bed is maintained."
What commonly used intravenous solution is hypotonic?
0.45% NaCl
The nurse is administering 1,000 mL 0.9 normal saline over 10 hours (set delivers 60 gtt/1 mL). Using the formula below, the flow rate would be:
100 gtt/min
You are to administer Morphine Sulfate 2gm in 50mL 0.9%NaCl to be infused over 30 minutes. At what rate do you program the infusion pump:
100 mL
You are to administer Cefizox 1,500 mg IV Push every 8 hours. It is available as Cefizox 2g powder with guideline directions that read reconstitute each 1g in 10mL sterile water and give slowly over 5 minutes. After you convert the milligrams to grams, you calculate the amount that you need to give. You determine that you need to administer how much medication? Once you know the amount of medication to administer, you calculate the infusion time. What do you determine the correct infusion time to be: Now that you have determined the amount of medication to administer and the infusion time, how much medication should you infuse every 15 seconds:
15 mL 7.5 minutes 0.5 mL
You are to administer 750 mL Lactated Ringer's solution over the next 5 hours by infusion pump. What do you program the rate to be:
150 mL/hr
You have an order for Lasix 80 mg IV STAT. You have available 10mg/mL concentration of lasix in a vial. Drug guide states not to exceed 40mg/ min when giving IV push. Over what period of time will you give this medication?
2 mins
A nurse is measuring the intake and output of a client who is dehydrated. What is the average adult daily fluid intake in milliliters that the nurse would use as a comparison?
2,500 mL
You are ordered to administer packed red blood cells 480 mL to infuse over 4 hours. The drop factor is 10 gtt/mL. You calculate the drip rate to be:
20 gtt/min
Your patient has an IV for the purpose of keeping the vein open in case venous access is needed. You know that the standard of care is that IV solutions must to be changed every:
24 hours
A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL?
3,000
You are to administer 750 mL Lactated Ringer's solution over the next 5 hours by gravity. The drip rate is 15gtts/mL. What is the desired drip rate:
38
You have an order for Lasix 80 mg IV STAT. You have available 10mg/mL concentration of lasix in a vial. Drug guide states not to exceed 40mg/ min when giving IV push. What volume will you administer per minute?
4 mL
The physician orders a continuous intravenous infusion of Heparin 40,000 units per day. You receive 20,000 units in 500 mL D5W from the pharmacy. How many mL per hour should the patient receive:
42 mL
You have an order to administer Ampicillin 500mg IV in 100mL of NS over the next 45 minutes. The drop factor is 20gtt/mL. You calculate the drip rate to be:
44
You are to administer 750 mL Lactated Ringer's solution over the next 5 hours by gravity. The drip rate is 20gtts/mL. What is the desired drip rate:
50
A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/mL. What is the flow rate?
50 gtt/min
A nurse needs to administer a continuous medication drip to a client. The nurse knows that, for a continuous infusion, she will likely need to add medication to which volume of IV solution?
500 to 1,000 mL
A physician has asked the nurse to use microdrip tubing to administer a prescribed dosage of IV solution to a client. What is the standard drop factor of microdrip tubing?
60 drops/mL
A client is reporting slight shortness of breath and lung auscultation reveals the presence of bilateral coarse crackles. The nurse has applied supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should not exceed:
6L/min
You are to administer 750 mL Lactated Ringer's solution over the next 5 hours by infusion pump. What do you program the VTBI:
750
An IV medication in 45 mL D5W is to be administered in 30 minutes. The drop factor is 60 gtts/mL. How many gtts/min would need to infuse if you were delivering the medication via gravity:
90 gtt/min
The nurse is conducting the physical assessment of a client at the health care facility. The nurse uses the pulse oximetry technique to monitor the oxygen saturation in the client's blood. Which pulse oximeter range indicates that the client is adequately oxygenated?
95% to 100%
What is the best device to use for a wound irrigation?
A 30mL syringe with an 18g needle
A nurse is caring for a client who has had a left-side mastectomy. The nurse notes a Penrose drain intact. Which statement is true about Penrose drains?
A Penrose drain promotes drainage passively into a dressing.
A nurse is administering a piggyback infusion to a client with second-degree burns. Which describes the most important feature of a piggyback infusion?
A parenteral drug is given in tandem with IV solution.
A nurse is using the RYB wound classification system to document patient wounds. Which wounds would the nurse document as a Y (yellow) wound?
A wound that is characterized by oozing from the tissue covering the wound A wound with drainage that is a beige color A wound that requires wound cleaning and irrigation
A client with type AB blood has experienced a precipitous drop in hemoglobin levels due to a gastrointestinal bleed and now requires a blood transfusion. Which blood types may this client safely receive?
AB A O B
Which interventions might a nurse be expected to perform when providing competent care for a client with a draining wound?
Administer a prescribed analgesic 30 to 45 minutes before changing the dressing, if necessary. Change the dressing midway between meals. Apply a protective ointment or paste, if appropriate, to cleansed skin surrounding the draining
Which actions would a nurse perform after selecting a site and palpating accessible veins in order to start an IV infusion?
Advance the needle or catheter into the vein. A sensation of "give" can be felt when the needle enters the vein. When blood returns through the lumen of the needle or the flashback chamber of the catheter, advance device into the vein until the hub is at the venipuncture site. Release the tourniquet, quickly remove the protective cap from the IV tubing, and attach the tubing to the catheter or needle.
Which of the following is the definition of family history?
Age and health or cause of death of blood relatives, health of close family members spouse and children, of various conditions such as stroke, heart disease, high blood pressure, diabetes, blood disorders, cancer, obesity, mental illness and others family tree genogram
A nurse is caring for a client who has a 6-cm × 8-cm wound caused by a motor vehicle accident. The wound is currently infected and draining large amounts of green exudate. A foul odor is also noted. The wound bed is moist with a yellow and red wound bed. Which dressing does the nurse anticipate is best to be ordered by the primary care provider?
Alginate (used in infected or noninfected wounds with moderate to heavy drainage. Alginates are used with moist wound beds with red and yellow tissue)
A nurse is caring for a client who had an appendectomy and has been readmitted for wound care. The incision has been opened by the primary care provider to allow for drainage. The wound is draining copious amounts of yellow exudate. Which type of dressing should the nurse understand is appropriate for this wound?
Alginates Antimicrobials Composites --> These all work with heavy drainage and infected wounds.
A client with a diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular access device is most likely to meet this client's needs?
An implanted central venous access device (CVAD)--> ideal for long-term use
You are caring for a patient who has a chest tube in place that is draining blood from a hemothorax. Which of the following items should you place in the patient's room to respond appropriately to accidental disconnection of the chest tube from the drainage device?
An unopened bottle of sterile water
A nurse is changing a peripheral venous access dressing for a client. Which of the following is a recommended step in this procedure?
Apply chlorhexidine using a back and forth friction scrub for at least 30 seconds.
A nurse flushing a capped, peripheral venous access device finds that the IV does not flush easily. What is the appropriate intervention in this situation?
Aspirate and attempt to flush the line again.
Which is a recommended guideline for the nurse who is administering a piggyback intermittent intravenous infusion of medication?
Attach infusion tubing to the medication container by inserting the tubing spike into the port with a firm push and twisting motion.
A nurse is using an IV port when administering medication to a client. Which IV administration has the greatest potential to cause life-threatening changes?
Bolus administration
A nurse needs to administer a prescribed medication to a client using IV push. In which way is the medication being administered to the client?
Bolus administration
Which actions should the nurse perform when cleansing a wound prior to the application of a new dressing?
Clean the wound from top to bottom. Use a sterile applicator to apply any ointment that is ordered. Use a new gauze for each wipe of the wound. Avoid touching the wound bed, whether with gloves or forceps.
A nurse is caring for a client with a chronic wound on the left buttock. The wound is 8.3 cm x 6.4 cm. Which action should the nurse use during wound care?
Cleanse with a new gauze for each stroke.
A new client is admitted to the hospital and requires a comprehensive admission assessment. What should the nurse include in this assessment?
Collection of subjective data Complete set of vital signs Functional ability evaluation
A nurse measures a client's 24-hour fluid intake and documents the findings. To be an accurate indicator of fluid status, what must the nurse also do with the information?
Compare the total intake and output of fluids for the 24 hours.
What is the best way for a nurse to obtain a database when performing an assessment of a client?
Complete a systematic nursing history and nursing examination
A nurse performs an assessment on a client who has been admitted to a long-term care facility for physical rehabilitation. What is the term for this type of assessment?
Comprehensive assessment
The plan of care for a postoperative patient specifies that lactated ringers solution be used to irrigate a wound. What should the nurse do after reading this information?
Continue with the dressing change as planned.
Which action should the nurse perform when applying negative pressure wound therapy?
Cut foam to the shape of the wound and place it in the wound.
A postoperative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client?
Dehiscence of the wound: Dehiscence is the partial or total separation of wound layers as a result of excessive stress on wounds that are not healed. Clients at greater risk for these complications include those who are obese or malnourished, smoke tobacco, use anticoagulants, have infected wounds, or experience excessive coughing, vomiting, or straining. An increase in the flow of fluid from the wound between postoperative days 4 and 5 may be a sign of an impending dehiscence. The client may say that "something has suddenly given way." If dehiscence occurs, cover the wound area with sterile towels moistened with sterile 0.9% sodium chloride solution and notify the physician. Once dehiscence occurs, the wound is managed like any open wound. Manifestations of infection include redness, warmth, swelling, and heat.
A medical-surgical nurse is assessing wounds of clients. Which wound complications are accurately described below?
Dehiscence, which is present when there is a partial or total disruption of wound layers Evisceration, which occurs when the viscera protrudes through the incisional area Postoperative fistula formation, most often the result of delayed healing, commonly manifested by drainage from an opening in the skin or surgical site
A nurse is caring for a client with phlebitis. The nurse notices that the client's forearm, which has the tubing, has become red and slightly warm. Which actions should the nurse perform to avoid further complications and provide relief to the client?
Discontinue the IV promptly.
The nurse just completed a dressing change and returned the client to a comfortable position. What should the nurse do next?
Document the color, odor, amount, and type of wound drainage.
The nurse is preparing to irrigate a client's wound. Arrange the following steps in the correct order.
Don a mask, gown, and eye protection. Carefully remove the soiled dressing. Don sterile gloves. Fill the irrigation syringe with warmed irrigation solution. Gently direct a stream of solution into the wound. Dry the surrounding skin with gauze dressings.
A physician is choosing a chest drainage system for a client who is ambulating daily. Which system would be the best choice for this client?
Dry suction/one-way valve system--> works even if knocked over, making it ideal for clients who are ambulatory.
What nursing interventions would be appropriate for a patient diagnosed with deficient fluid volume?
Electrolyte management Intravenous therapy Nutrition management
A nurse is caring for a client who has a Jackson-Pratt drain. Which of the following is the order in which the nurse should carry out these interventions?
Empty the drain chamber's contents Use a gauze pad to clean the drain's outlet Fully compress the chamber and replace the cap Measure and record the character and amount of drainage Change gloves Change dressing to drain site
A nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV?
Ensure that the prescribed solution is clear and transparent.
Which of the following statements is an appropriate nursing diagnosis for an client 80 years of age diagnosed with congestive heart failure, with symptoms of edema, orthopnea, and confusion?
Extracellular Volume Excess related to heart failure, as evidenced by edema and orthopnea
A nurse is caring for a client who has a PICC line. Which nursing action is recommended?
Flush using normal saline and/or heparin solution according to facility policy.
What characteristics would you observe for in a wound healing by secondary intention? Select all that apply.
Granulation tissue Contraction effect Potential for tunneling
A nurse is caring for a client who suddenly begins to have respiratory difficulty. In what position would the nurse place the client to facilitate respirations?
High-Fowler's
The nurse is assisting with a client's blood transfusion. What type of reactions may occur during this procedure?
Hives, itching, and anaphylaxis may occur during an allergic reaction. Fever, chills, headache and malaise may occur during a febrile reaction. Facial flushing, fever, chills, headache, low back pain, and shock may occur during a hemolytic transfusion reaction.
A physician orders a wound irrigation to apply an antiseptic to a client's wound. The nurse will follow which guideline for performing this procedure?
If the wound is closed, clean technique may be used instead of sterile technique.
When providing chemotherapeutic agents, which catheter is accessed with a noncoring needle?
Implanted venous access (Huber point needle)
A nurse is beginning to conduct a health history for a client with respiratory problems. He notes that the client is having respiratory distress. What would the nurse do next?
Initiate interventions to help relieve the symptoms.
A nursing instructor is teaching a class on the mechanics of respiration and the process of ventilation. The instructor determines that the education was successful when the students identify which activity as occurring during inspiration?
Intercostal muscles contract.
Which solution is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume?
Isotonic
A nursing responsibility in managing IV therapy is to monitor the fluid infusions and to replace the fluid containers as needed. What is an accurate guideline for IV management that the nurse should consider?
It is the responsibility of the nurse to provide ongoing verification of the IV solution and the infusion rate with the physician's order.
A nurse is caring for a client on IV therapy. The IV tubing has a volume-control set. Which of the following is a function of the volume-control set?
It is used to administer small volumes of IV medication.
Which nursing actions would be performed when preparing an IV solution and tubing to initiate intravenous therapy?
Maintain aseptic technique when opening sterile packages and IV solution. Clamp tubing, uncap spike, and insert into entry site on bag as manufacturer directs. Remove cap at end of tubing, release clamp, and allow fluid to move through tubing. Apply label to tubing reflecting the day/ date for next set change, per facility guidelines.
A nurse is caring for a client on a medical-surgical unit. The client has a wound on the ankle that is covered in eschar and slough. The primary care provider has ordered debridement in the surgical department for the following morning. Which type of debridement does the nurse understand has been ordered on this client?
Mechanical debridement
A client visits the health care facility for a scheduled physical assessment. What should the nurse do when physically assessing the quality of the client's oxygenation?
Monitor the client's respiratory rate. Check the symmetry of the client's chest. Observe the breathing pattern and effort.
You are providing endotracheal tube care to your patient who is on a mechanical ventilator. To follow proper procedure when changing the tape you are sure to do which of the following. Select all that apply.
Move the ET tube to the alternate side of the mouth Check the ET tube markings to ensure accurate placement Assess the patient for the need for pain medication Assess breath sounds and respiratory status after taping
During a dressing change, the nurse assesses protrusion of intestines through an opened wound. What would the nurse do after covering the wound with towels moistened with sterile 0.9% sodium chloride solution?
Notify the physician and prepare for surgery.
A nurse monitoring a client's IV infusion auscultates the client's lung sounds and finds crackles in the bases of lungs that were previously clear. What would be the appropriate intervention in this situation?
Notify the primary care provider immediately for possible fluid overload.
A nurse assessing the skin of clients knows that the following are health states that may predispose clients to skin alterations.
Obesity Excessive perspiration Low BMI
You are caring for a patient who has a chest tube placed after thoracic surgery. You know that principles of caring for patients with chest drainage units include which of the following.
Observe for tidaling in the water seal chamber Observe for gentle bubbling in the suction chamber
The nurse is preparing to obtain biographical data from a client before initiating a health assessment. Which of the following data should the nurse plan to collect? Select all that apply.
Occupation Gender Name Date of birth
A client who has a bacterial infection develops an abscess that needs to be drained. What drainage system would most likely be used in this situation?
Penrose drain
The nurse would recognize which of these devices as an open drainage system?
Penrose drain
The dressing change on a deep upper-arm wound is painful for the client. When preparing a care plan for the client, the nurse will incorporate which nursing measure?
Plan to administer a prescribed analgesic 30 to 45 minutes prior to the dressing change.
Which actions would a nurse be expected to perform when applying a saline-moistened dressing to a client's wound?
Position the client so the wound cleanser or irrigation solution will flow from the clean end of the wound toward the dirtier end. Carefully and gently remove the soiled dressings; if there is resistance, use a silicone-based adhesive remover to help remove the tape. Gently press to loosely pack the moistened gauze into the wound; if necessary, use forceps or cotton-tipped applicators to press gauze into all wound surfaces.
Healing benefits of using vacuum assisted closure include which of the following. Select all that apply.
Promotes angiogenesis Promotes increased circulation Decreases microbial bioload Promotes the contraction effect
What are functions of the skin?
Protection Temperature regulation Sensation Immunologic
A nurse is developing a plan of care for a client who is at high risk for developing pressure ulcers. Which intervention should the nurse include in the plan to prevent the development of pressure ulcers?
Provide incontinent care every 2 hours and as needed. Turn client every 2 hours while client in bed. Encourage client to take fluids every 2 hours.
A nurse inadvertently partially dislodges a PICC line when changing the dressing. What would be the appropriate intervention in this situation?
Reapply the dressing and notify the physician for further instructions.
The nurse is caring for a client who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and adheres to the wound bed. Which modification is most appropriate?
Reduce the time interval between dressing changes.
The nurse is determining a site for an IV infusion. What guideline should the nurse consider?
Scalp veins should be selected for infants because of their accessibility.
Following preparation of the IV solution and tubing, what nursing actions would be performed by the nurse when selecting a site and palpating a vein to start an IV infusion?
Select an appropriate site and palpate accessible veins. Direct the ends of the tourniquet away from the site and check that the radial pulse is still present. If a vein cannot be felt, release the tourniquet and have the client lower the arm below the level of the heart to fill the veins.
A specially trained nurse has inserted a PICC line. What would be done next?
Send the client to the radiology department.
A nurse monitoring an IV infusion notes the signs and symptoms of a thrombus. What nursing interventions would the nurse perform?
Stop the infusion immediately. Apply warm compresses as ordered by the primary care provider. Restart the IV at another site.
The nurse is administering medication to a client through a drug-infusion lock using the saline flush. During the process, the client complains of pain at the site. Which interventions are appropriate in this situation?
Stop the medication and assess the site for signs of infiltration and phlebitis. Flush the medication lock with normal saline again to recheck patency. If site is within normal limits, resume medication administration at a slower rate.
During a blood transfusion of a client, the nurse observes the appearance of rash and flushing in the client, although the vital signs are stable. Which intervention should the nurse perform for this client first?
Stop the transfusion immediately.
While the nurse is providing morning hygiene for a client who has a chest tube, the client has rolled over quickly and the chest tube has become disconnected from the drainage unit. How should the nurse first respond to this event?
Submerge the end of the tube in sterile water.
When caring for a client with a tracheostomy, the nurse would perform which recommended action?
Suction the tracheostomy tube using sterile technique.
What signs of complications and their probable causes may occur when administering an IV solution to a client?
Swelling, pain, coolness, or pallor at the insertion site may indicate infiltration of the IV. Redness, swelling, heat, and pain at the site may indicate phlebitis. Local or systemic manifestations may indicate an infection is present at the site.
An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as:
TPN
What can a nurse ask a patient to do before suctioning to prevent hypoxemia?
Take several deep breaths
The nurse is caring for a patient who has been receiving intravenous therapy for 48 hours when the IV site is observed to be cool and pale and edematous. What do you suspect from these symptoms
The IV has infiltrated; discontinue IV and apply a warm compress
The nurse is observing the unlicensed assistive personnel (UAP) perform oropharyngeal suctioning on a client. Which action, performed by the UAP, would indicate to the nurse that suctioning is being properly performed?
The UAP advances the catheter approximately 3" to 4" to reach the pharynx.
When inspecting a client's chest to assess respiratory status, the nurse should be aware of which normal finding?
The chest should be slightly convex with no sternal depression.
A physician prescribes the use of water-seal chest tube drainage for a client at a health care facility. What should the nurse ensure when using the water-seal chest tube drainage?
The chest tube should not be separated from the drainage system unless clamped.
Mrs. Harris was admitted to the psychiatric unit 3 days ago with a diagnosis of major depressive disorder. The client answers assessment questions with barely audible "yes" or "no" responses and tells the nurse that she has been depressed for a long time. She wants the door and the curtains drawn to darken her room. She refuses visitors, eats only 25% of her meals, and tells the nurse that the food makes her nauseous. The nurse observes the client biting her fingernails. She cries often and sleeps a lot. The nurse documents which client actions as objective assessment data? (Select all that apply.)
The client bites her fingernails. The client sleeps a lot. The client answers questions in a barely audible voice. The client eats 25% of her meals.
A nurse assessing client wounds would document which examples of wounds as healing normally without complications?
The edges of a healing surgical wound appear clean and well approximated, with a crust along the edges. a wound that does not feel hot upon palpation a wound that forms exudate due to the inflammatory response
A nurse is sitting near a client while conducting a health history. The client keeps edging away from the nurse. What might this mean in terms of personal space?
The nurse is in the client's personal space.
The nurse is caring for a Penrose drain for a client post-abdominal surgery. What nursing action reflects a step in the care of a Penrose drain that needs to be shortened each day?
The nurse pulls the drain out a short distance using sterile scissors and a twisting motion, then cuts off the end of the drain with sterile scissors.
The nurse caring for a postoperative client is cleaning the client's wound. Which nursing action reflects the proper procedure for wound care?
The nurse works outward from the wound in lines parallel to it.
A nurse uses an infusion pump to administer the IV solution to a client. The nurse is aware that an infusion pump adjusts the pressure according to the resistance it meets and there is a possibility that the needle may get displaced. How would a change in the needle's position affect the infusion pump?
The pump will continue to infuse fluid even when the needle is displaced.
Which statement accurately describes a guideline when using an implanted port venous access device?
The system is accessed with a noncoring needle and patency is maintained by periodic flushing.
A nurse caring for a client who has a surgical wound following a cesarean section notes dehiscence of the wound and contacts the surgeon. Which is a finding related to this condition?
There is an unintentional separation of the wound.
The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds?
They are low-pitched, soft sounds heard over peripheral lung fields.
A nurse needs to select a venipuncture site to administer a prescribed amount of IV fluid to a client. The nurse looks for a large vein when using a needle with a large gauge. What explains the nurse's action?
To prevent compromising circulation
A nurse is caring for a client with a nonhealing stage IV pressure ulcer. The nurse observes an area in the wound that is hollow between the outer surface and the wound bed. What is the correct term for this condition?
Undermining (a hollow area between the outer wound and the wound bed. It resembles a cave)
A nurse is performing negative pressure wound therapy on a client with a wound in his left ischial tuberosity area. Place in the correct order the steps that the nurse should perform during this dressing change.
Use sterile gloves. Cut the foam to the shape and measurement of the wound. Place the drape to cover the wound and an additional 3 to 5 cm. Cut a 2-cm hole in the drape. Apply a vacuum device to wound. Ensure that negative pressure has been achieved.
Which actions should a nurse perform when inserting an oropharyngeal airway?
Wash hands and put on PPE, as indicated. Rotate the airway 180 degrees as it passes the uvula. Remove airway for a brief period every 4 hours or according to facility policy
You are assessing the wound of a patient prior to repacking the wound. You know that the ideal environment to promote wound healing is that the:
Wound is moist and the surrounding skin is dry
What prevents air from reentering the pleural space when chest tubes are inserted?
a closed water-seal drainage system
Your patient has had a blood transfusion infusing for 15 minutes when he starts to become tachycardic, has a slight increase in temperature, and complains of lower back discomfort. Based on these symptoms, you are concerned that the patient may be experiencing what type of transfusion reaction:
a hemolytic transfusion reaction
Which of the following patient situations would you expect the use of pneumatic compression devices?
a patient with pelvic surgery
What function does a wet to moist dressing have that a wet to dry dressing does not?
a wet to moist heals
Which client will have more adipose tissue and less fluid?
a woman
Immediately following the removal of your patient's chest tube, you expect the patient to have which of the following? Select all that apply.
an occlusive dressing chest x-ray ordered
A client is experiencing hypoxia. Which nursing diagnosis would be appropriate?
anxiety
When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which intervention should the nurse perform for this complication?
apply a warm compress
A duoderm dressing promotes what type of debridement?
autolytic
A nurse is caring for a client who has a wound with a large area of necrotic tissue. The health care provider has ordered fly larvae to debride the wound. Which of the following types of debridement does the nurse understand has been ordered?
biosurgical debridement--> Biosurgical debridement uses fly larvae to clear the wound of necrotic tissue. This is accomplished through an enzyme the larvae releases. Autolytic debridement involves using the client's own body to break down the necrotic tissue. Enzymatic debridement involves the use of synthetic enzymes that break down necrotic tissue when applied to the wound bed. Mechanical debridement involves physically removing the necrotic tissue, such as surgical debridement.
A nurse is caring for a client who has a pressure ulcer on the left great toe. The client is scheduled for debridement the next morning. Based on the red-yellow-blue (RYB) Wound Classification System, which of the following classifications should the nurse document?
black classifiation
Upon auscultation of the client's lungs, the nurse hears loud, high-pitched sounds over the larynx. What term will the nurse use in documentation to describe this breath sound?
bronchial
A nurse is choosing a vein to start an IV infusion in a client. What are recommended veins to use when initiating an IV infusion?
cephalic vein metacarpal basilic veins superficial veins on the dorsal aspect of the hand
When providing care for a client who has a peripheral intravenous catheter in situ, the nurse should:
change the site every three to four days.
The nurse is assessing a client with lung cancer. What manifestations may suggest that the client has chronic hypoxia?
clubbing
The nurse is informed while receiving a nursing report that the client has been hypoxic during the evening shift. Which assessment finding is consistent with hypoxia?
confusion
You are preparing your patient for the insertion of a tracheotomy tube. Your patient has excessive secretions and is at risk for aspiration. You expect the physician to put in a:
cuffed tube
The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound?
desiccation: Desiccation is localized wound dehydration. Maceration is localized wound overhydration or excessive moisture.
A patient is having a blood transfusion, but the fluid is dripping very slowly. The blood has been infusing for more than 4 hours. What should the nurse do next:
discontinue the blood transfusion
A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom?
distended neck veins
The nurse caring for client that had abdominal surgery 12 hours ago notes a small amount of sanguineous drainage on the abdominal surgical dressing. What is the appropriate action by the nurse?
document the findings
Your patient has a continuous IV at 75mL per hour. You know to assess the IV site and infusion:
every hour
A normal pulse oximetry reading indicates that the body's oxygen demands are being met.
false
Within 15 minutes after the start of a blood transfusion, the client complains of chills and headache. During frequent vital signs, the nurse begins to see an elevation in the temperature. What condition is the client experiencing?
febrile reaction
The nurse is conducting a respiratory assessment of a client age 71 years who has been recently admitted to the hospital unit. Which assessment finding should the nurse interpret as abnormal?
fine crackles to the bases of the lungs bilaterally
A woman fell from a truck and required abdominal surgery to repair lacerations of the abdomen and bowel. The client now has constant drainage from a wound that will not heal on the surface of the abdomen. The client has a(an)
fistula (an abnormal tubelike passageway that forms from one organ to outside the body)
When an older adult client receiving a blood transfusion presents with an elevated blood pressure, distended neck veins, and shortness of breath, the client is most likely experiencing:
fluid overload.
The client is admitted to the nurse's unit with a diagnosis of heart failure. His heart is not pumping effectively, which is resulting in edema and coarse crackles in his lungs. The term for this condition is:
fluid volume excess
The nurse's morning assessment of a client who has a history of heart failure reveals the presence of 2+ pitting edema in the client's ankles and feet bilaterally. This assessment finding is suggestive of:
fluid volume excess.
Which type of wound drainage should alert the nurse to the possibility of infection?
foul-smelling drainage that is grayish in color
During a blood transfusion, a client displays signs of immediate onset facial flushing, fever, chills, headache, low back pain, and shock. Which transfusion reaction should the nurse suspect?
hemolytic transfusion reaction: incompatibility of blood product
A nurse is preparing to administer a medication by intravenous piggyback. Where will the piggyback container be placed?
higher than the primary solution container
The nurse is discussing care of a client's wound that has nonviable tissue in the base with the wound care nurse. The wound care nurse recommends that the nurse utilizes a dressing that would promote autolytic debridement of the wound. Which of the following dressings should the nurse select?
hydrocolloid--> to promote autolytic debridement of the wound
A nurse is percussing the thorax of a patient with chronic emphysema. What percussion sound would most likely be assessed?
hyperresonance
A client who is admitted to the health care facility has been diagnosed with cerebral edema. Which intravenous solution needs to be administered to this client?
hypertonic solution
A client suffering from chronic obstructive pulmonary disease (COPD) reports that it is hard to cough up secretions and they are thick and sticky. The nurse should instruct the client to:
increase her fluid intake to thin secretions
In what age group would a nurse expect to assess the most rapid respiratory rate?
infants
A home care nurse makes the following assessments of a wound: increased drainage and pain, increased body temperature, red and swollen wound, and purulent wound drainage. What wound complication do these assessments indicate?
infection
A homecare nurse makes the following assessments of a wound: increased drainage and pain, increased body temperature, red and swollen wound, and purulent wound drainage. What wound complication do these assessments indicate?
infection
A student is learning how to administer intravenous fluids, including accessing a vein. Although all of the following may occur, which is the most potentially harmful risk posed for the patient when accessing the vein:
infection
A student is learning how to administer intravenous fluids, including accessing a vein. What is the most potentially harmful risk posed for the client when accessing the vein?
infection
A nurse assessing the IV site of a client observes swelling and pallor around the site, and notes a significant decrease in the flow rate. The client reports coldness around the infusion site. What IV complication does this describe?
infiltration
A patient has had a tracheostomy and the nurse is prepared to conduct tracheostomy care. What part of the tracheostomy tube is removed for cleaning?
inner cannula
A nurse is caring for a client who has recently undergone hernial surgery. What are possible causes of complications with regard to surgical wounds?
insufficient protein and vitamin C intake weak tissue and muscular support due to obesity distension of the abdomen from accumulated intestinal gas
A client has an order for an intermittent infusion of 250 mL of 0.9 normal saline. The nurse understands that this type of infusion is used for which situation?
medications that need to be infused over 20 to 60 minutes
You are preparing the tubing for your patient who is to have a blood transfusion. To prime the blood tubing, you know to use what solution:
normal saline
The type of suctioning that suctions the back of the throat through the mouth is called
oropharyngeal suctioning
Which of the following locations might the nurse use to assess the condition of an insertion site for a central venous access device:
over the jugular vein
While examining a client, the nurse palpates the client's chest and back. What would the nurse expect to identify with this technique?
pattern of thoracic expansion
To assess a newly admitted adult client's perception of reality, the nurse asks the client about:
person, place, and time.
A client with dehydration is being administered IV fluids. During rounds, the nurse noticed that the skin immediately surrounding the IV site was reddish in color and showing signs of inflammation. The nurse recognizes that what phenomenon is likely responsible?
phlebitis
Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms indicative of:
phlebitis
A client with renal disease requires IV fluids. It is important for the nurse to:
place the fluids on an electronic device.
A nurse is teaching a nursing student about surgical drains and their purposes. Which of the following would the nursing student understand is the purpose for a t-tube drain?
provides drainage for bile (after a cholecystectomy)
During a skin assessment, the nurse recognizes the first indication that a pressure ulcer may be developing when the skin is which color during the application of light pressure?
red
A client has a physician's order for n.p.o (nothing by mouth) following abdominal surgery to repair a bowel obstruction. The client has a nasogastric tube inserted to low intermittent suction. The client requires intravenous therapy for what purpose?
replace fluid and electrolytes
A woman age 58 years is suffering from food poisoning after eating at a local restaurant. She has had nausea, vomiting, and diarrhea for the past 12 hours. Her blood pressure is 88/50 and she is diaphoretic. She requires:
replacement of fluids for those lost from vomiting and diarrhea.
A nurse is caring for a client at a wound care clinic. The client has a 5-cm × 6-cm abdominal wound dehiscence. Which type of wound repair would the nurse expect with this wound?
secondary intention
A specially trained nurse has inserted a PICC line. What would be done next:
send the patient to the radiology department
A nurse caring for a postoperative client observes the drainage in the client's closed wound drainage system. The drainage is thin with a pale pink-yellow color. The nurse documents the drainage as:
serosanguineous.
A nurse is documenting a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a watery pink drainage on the dressing. Which drainage types should the nurse document?
serosanguinous
Which normal conditions would a nurse expect to find when performing a physical assessment of a client's respiratory system?
slightly contoured chest with no sternal depression anteroposterior diameter of the chest less than the transverse diameter bronchial, vesicular, and bronchovesicular breath sounds
You are caring for a patient with a chest tube. For patient safety you check to be sure you have the necessary emergency equipment at the bedside including which of the following. Select all that apply.
sterile saline kelley clamps
Which nursing skill requires the nurse to use sterile technique?
suctioning a tracheostomy
What are components of a medication order?
the full name of the client the date and sometimes the time when the order is written the dosage of the drug, stated in either the apothecary or metric system
Your patient has a double lumen fenestrated tracheostomy tube. When auscultating the lungs, you find that the patient has significant rhonchi and you determine that you should perform nasopharyngeal suctioning. Prior to suctioning the patient, you make sure that:
the inner cannula is in place
When capping a primary line for intermittent use, a nurse notices local, acute tenderness; redness, warmth, and slight edema of the vein above the insertion site. What is the most likely complication that has occurred?
thrombus
A client with an infection is receiving intravenous antibiotic therapy. The client has an intermittent infusion device in place. The nurse flushes the device with normal saline solution before administering the antibiotic based on which rationale?
to prevent blood clot formation
A nurse suctioning a client through a tracheostomy tube should be careful not to occlude the Y-port when inserting the suction catheter because it would cause what condition to occur?
trauma to the tracheal mucosa
After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding.
true
A nurse is assessing wound drainage during the immediate postoperative period for a client who has had a gall bladder removed. In addition to assessing the dressing, where should the nurse check for drainage?
under the client
Which of the following drains require the use of an occlusive dressing?
vacuum drain
During data collection, the nurse auscultates low-pitched, soft sounds over the lungs' peripheral fields. Which appropriate terminology would the nurse use to describe these lung sounds when documenting?
vesicular
A nurse is caring for a client who has a wound on the right thigh from an axe. The nurse is using the RYB wound classification system and has classified the wound as "Yellow". Based on this classification which of the following nursing actions should the nurse perform?
wound irrigation
Which question or statement would be an appropriate termination of the health history interview?
"Can you think of anything else you would like to tell me?"
A new graduate nurse has come to your floor to work. She asks the charge nurse what the difference is between collecting data in the nursing assessment and in the evaluation phase of the nursing process. The charge nurse bases her response on her knowledge of which of the following statements?
"Data collected in the nursing assessment identifies patient health problems, whereas data collected in the evaluation phase is to determine if patient outcomes are being achieved."
The nurse is taking care of a client on the second post-operative day who asks about wound dehiscence. Which response by the nurse is most accurate?
"Dehiscence is when a wound has partial or total separation of the wound layers."
Which question about fluid balance would be appropriate when conducting a health history for a client?
"Describe your usual urination habits."
A nurse is conducting an interview with a patient to collect a medication history. Which of the following questions would be used to ensure safe medication administration?
"Do you have any allergies to medications?"
A nurse is conducting a health history interview for a woman at an assisted-living facility. The woman says, "I have been so constipated lately." How should the nurse respond?
"Do you take anything to help your constipation?"
A young man who has had a traumatic mid-thigh amputation of his right leg refuses to look at the wound during dressing changes. Which response by the nurse is appropriate?
"I respect your wish not to look at it right now."
A nurse is providing discharge instructions for a client who had a colon resection and has a Hemovac drain in place. Which statement indicates that the client understands?
"I will squeeze the chamber and apply the cap to maintain negative pressure."
A nurse is explaining a chest tube to family members who do not understand where it is placed. What would the nurse tell them?
"It is inserted into the space between the lining of the lungs and the ribs."
An adolescent comes to a community health clinic reporting vaginal itching and discharge. She believes it is from having sex with her boyfriend. Which response should the nurse use during the health history to elicit information?
"Tell me about the sexual activity with your boyfriend."
A nurse is conducting a health history for a client with a skin problem. What question or statement would be most useful in eliciting information about personal hygiene?
"Tell me about what you do to take care of your skin."
Which question or statement would be appropriate in eliciting further information when conducting a health history interview?
"Tell me more about what caused your pain."
