MCN Lab

Three way catheter

A client is for transurethral resection of the prostate gland (TURP). The nurse would prepare what type of urinary catheter after TURP? Straight catheter Condom catheter Foley catheter Three way catheter

: Maintain the container in an ice slush bath and transport immediately to the laboratory on ice or ice cooler

A 35-year-old client is for 24-hour-urine collection , Which of the following instructions of the nurse is to be implemented on starting of the collection?EXCEPT Maintain the container in an ice slush bath and transport immediately to the laboratory on ice or ice cooler. Have the client void totally empty the bladder and discard this urine. Explain the procedure to the client. Inform about the importance of staying away from certain foods like coffee, citrus foods, banana while collecting the urine.

The bladder tone has been regained

A client on bladder complained of having "urge to void" while the catheter is clamped. What is the indication of this? The client can't be weaned from catheter The client's bladder was traumatized The client has developed infection (cystitis). The bladder tone has been regained

0.9% normal saline solution

A client was brought to the emergency room with complaints of slurring of speech, vomiting, dry mucosa, and dry skin turgor. Lab tests showing serum sodium 125 mEq/L and serum blood glucose of 350 mg/dL. Nurse Sophie will anticipate the physician to initially order which of the following intravenous solutions? 0.45% normal saline solution 5% dextrose in water (D5W) 0.9% normal saline solution 10% dextrose in water (D10W)

glycosylated hemoglobin level

A female client tells nurse Nikki that she has been working hard for the last 3 months to control her type 2 diabetes mellitus with diet and exercise. To determine the effectiveness of the client's efforts, the nurse should check: fasting blood glucose level. serum fructosamine level. glycosylated hemoglobin level. urine glucose level.

: Sunken fontanels.

A nurse is caring for an infant who has a high bilirubin level and is receiving phototherapy. Which of the following is the priority finding in the newborn? Maculopapular skin rash. Bronze skin discoloration. Sunken fontanels. Conjunctivitis.

Evaluate the patient's circulation and vital signs

A patient returns from surgery with an indwelling urinary catheter in place and empty. Six hours later, the volume is 120 ml. The drainage system has no obstructions. Which interventions has priority? Give a 500 ml bolus of isotonic saline Place the patient in the shock position, and notify the surgeon Evaluate the patient's circulation and vital signs Flush the urinary catheter with sterile water or saline

: the first drop of blood contains greater proportion of serous fluid.

After the skin is punctured, the first drop of blood is wiped away with a cotton ball because the first drop of blood is smeared. the first drop of blood is contaminated with alcohol the first drop of blood is contaminated with germs the first drop of blood contains greater proportion of serous fluid

Clean the site with antiseptic swab and allow alcohol to dry

Before obtaining blood specimen, the nurse must do which of the following action to get accurate result. Clean the site using dry technique. Clean the site with antiseptic swab and allow alcohol to dry. Clean the site with antiseptic swab and pierce the site immediately before the alcohol dries. Clean the site with antiseptic swab and massage the site to improve blood flow to the area.

30-45 degrees

In collection of urine specimen from the Catheter , clamp the drainage tubing for 30 minutes then Wipe the area where the needle will be inserted with a disinfectant swab. Insert the needle at what angle to collect urine from the port to avoid through and through? 15-30 degrees 10-15 degrees 45-90 degrees 30-45 degrees

Provides easy access during catheter removal.

In removing a straight (intermittent) or indwelling catheter , Loosen syringe withdraw plunger inset hub of syringe into inflation bulb, allowed balloon fluid to drain into syringe, ensure that the entire amount of fluid was remove. The rationale for these is the following EXCEPT Provides easy access during catheter removal. Partially inflated balloon can traumatize urethral wall during removal. These ridges can cause discomfort or trauma during removal. Passive drainage of catheter balloon will prevent formation of ridges in balloon.

: Hold the finger in a dependent position and massage it towards the site.

In selecting and preparing the vascular puncture site, the nurse must Hold the finger in a dependent position and massage it towards the site. Wrap the finger first in a warm cloth for 3 to 5 minutes. Rub the earlobe briskly with a small piece of gauze. Select the side of the finger beside the bone

True

Infants who are born too early, before 37 weeks, can have problems such as low birth weight, irregular temperature, and unstable vital signs. An incubator helps control their temperature. False True

increase the blood flow to the area, ensure an adequate specimen and reduce the need of a repeat puncture.

Prior to puncturing the site for CBG testing, Nurse Jane holds the finger of her patient in a dependent position and massage it toward the site. These are done to : have a good grasp of the injection site. this position ensures accuracy of the test result provide comfort and lessen the pain of the patient. increase the blood flow to the area, ensure an adequate specimen and reduce the need of a repeat puncture.

extreme temperature could affect the strips and alter the results of the tests.

Patient Val is complaining to patient Darell that he has been getting erratic reading from his glucometer. When asked where he store his glucometer, he mentioned that his meter and strips are kept in his car compartment. As a nurse you are aware that: Nurse Darell must inform patient Val to plavce the strips in a cold environment first before taking the test. As long as the strips are not expired it can and should be used and will provide accurate results. extreme temperature could affect the strips and alter the results of the tests. his blood test results are accurate and valid.

: to determine or monitor venous or arterial blood glucose levels of clients at risks for hyperglycemia or hypoglycemia

The following are purposes of CBG monitoring except? to determine or monitor venous or arterial blood glucose levels of clients at risks for hyperglycemia or hypoglycemia to promote blood glucose regulation by the client to determine or monitor blood glucose levels of clients at risks for hyperglycemia or hypoglycemia to evaluate the effectiveness of insulin administration

: 90 degree angle

The lancet is designed to pierce the skin at specific depth when in what position? 75 degree angle 15 degree angle 90 degree angle 45 degree angle

Save all urine in a container for 24 hours and store in a cooler

The nurse is preparing to care for the client for 24 hour urine collection. Which of the following would the nurse include in the plan of care? Instruct client to take more fluids including coffee and tea to get enough specimen. Place the client in radiation precaution for 18 hours Save all urine in a container for 24 hours and store in a cooler. Collect urine in 24 hours starting with the first voided urine in the morning.

improving voiding function

The nurse must assess the following in collecting specimen from a foley catheter or drainage tube EXCEPT for presence of clinical signs of UTI client's ability to provide specimen improving voiding function color, odor, consistency of the urine

10 cc disposable syringe

The nurse will remove the client's indwelling catheter, what equipment the nurse need to prepare Specimen bottle Plaster tape 10 cc disposable syringe Sterile gloves

: Higher than 126 mg/dl

The nurse working in the physician's office is reviewing lab results on the clients seen that day. One of the clients who has classic diabetic symptoms had an eight-hour fasting plasma glucose (FPG) test done. The nurse realizes that diagnostic criteria developed by the American Diabetes Association for diabetes include classic diabetic symptoms plus which of the following fasting plasma glucose levels? Higher than 126 mg/dl Higher than 160 mg/dl Higher than 140 mg/dl Higher than 106 mg/dl

: Place the needle in the container that reads " infectious"

The student nurse is collecting urine from the catheter. Which of the following actions would require further instruction from his Instructor? Unclamp the tubing while collecting the urine Clean the tubing before inserting the needle at 45% angle Place the needle in the container that reads " infectious" Clamp the tubing for 30 min before collecting urine from the catheter

Pressure will promote hemostasis

Upon completion of the procedure, pressure must be applied to the puncture site with a cotton ball. The rationale for the action is Pressure will assist in homeostasis Pressure will relieve pain Pressure will promote hemostasis Pressure prevents edema formation.

Check for kinks in the outflow tubing

What should you do when you notice that the return fluid in the urinary catheter is slowly draining? Check for kinks in the outflow tubing Ask the patient to cough. Raise the drainage bag above the level of the abdomen Place the patient in a reverse Trendelenburg position

Color, odor, and consistency of urine

When collecting specimen from a foley catheter, which of the following data is assessed? Color, odor, consistency and time of collection Color, odor, consistency and temperature of urine. Color, odor, and consistency of urine Color, odor, consistency and amount of urine

Dietary intake

When developing a plan of care for a client newly diagnosed with gestational diabetes, which of the following instructions would be the priority? Medication Exercise Dietary intake Glucose monitoring

Set up specific times to empty the bladder

Which action most important during bladder training in a patient with a neurogenic bladder? Encourage the use of an indwelling urinary catheter Set up specific times to empty the bladder Encourage Kegel exercise Force fluids

: Bright green

While changing the infant's diaper who is undergoing phototherapy, the nurse will expect which of the following color of stools? Bright green Golden yellow Light yellow Light brown

Delay catheterization and notify the doctor

You're preparing for urinary catheterization of a trauma patient and you observe bleeding at the urethral meatus. Which action has priority? Delay catheterization and notify the doctor Heavily lubricate the catheter before insertion Irrigate and clean the meatus before catheterization Check the discharge for occult blood before catheterization

Gauge of the lancet used

n documenting the result of the test, the following data must be included except Method of testing Gauge of the lancet used. CBG result The amount, type, route and time of insulin administration.

The first and second statement are true

n preparing the equipment the reagent strip is placed on a warm dry paper towel. Moisture can change the strip, thereby altering test results. The first is statement is false, the second statement is true The first statement is true, the second statement is false The first and second statement is false. The first and second statement are true

character and amount of urine

which of the following during Evaluation on Catheterization , the nurse must observe , to determine if the urine is flowing adequately. level of discomfort character and amount of urine patient can bear down no urine leaking from catheter or tubing connections for indwelling catheter.