Nursing Skills 2

A newly admitted client. with type. 1 diabetes asks the nurse what caused her diabetes. When the nurse is explaining to the client the etiology of type 1 diabetes, what process should the nurse describe?

"Destruction of special cells in the pancreas causes a decrease in insulin production. Glucose levels rise because insulin normally breaks it down."

The management of the client's gastrostomy is an assessment priority for the home care nurse. What statement would indicate that the client is managing the tube correctly?

"I flush my tube with water before and after each of my medications

A nurse is documenting the appearance of feces from a patient with a permanent ileostomy. Which of the following would she document?

"Illeostomy bag half filled with liquid feces."

The infection control nurse is reviewing data for the medical-surgical unit. The nurse notices an increase in postoperative infections from Aspergillus. Which type of health care associated infection will the nurse report?

.Exogenous

When flushing an adult PICC line, the minimum volume of the syringe must be

10 ml

It is recommended that the port of a central line be wiped for a minimum of how many seconds prior to accessing

15 seconds

When drawing a blood sample from an adult central line, a waste volume of _ must be drawn pre-sample, with a _ post sample flush A- 5ml and 10 ml. B- 10ml and 20ml. C- 15ml and 10ml. D- 10ml and 10ml

5ml and 10ml

A client with an indwelling catheter is prescribed to receive sterile normal saline bladder irrigation at 100 ml/hr. After an 8 hour shift the nurse measures the client's output as being 1425ml. What is the clients urine output for the 8 hour shift?

625 ml

What would the critical care nurse recognize as a condition that may indicate a client's needs to have a tracheostomy?

A client requires permanent ventilation

There are many reasons for a patient to have a central line inserted. SATA. A-chemotherapy. b- access for frequent labwork. C- lack of peripheral acces. D- long-term antibiotics.

A-chemotherapy. b- access for frequent labwork. C- lack of peripheral acces. D- long-term antibiotics.

What is the correct order to mix NPH insulin with Regular insulin?

Air to NPH, air to Regular, draw up regular, draw up NPH

The patient has contracted a urinary tract infection while in the hospital. Which action will most likely increase the risk of a patient contracting a uti?

Allowing the drainage bag port to touch the graduated receptacle.

The nurse has completed care with a client who has a new ostomy. What should the nurse document about the care provided? SATA

Any change in stoma size, Condition of the skin around the stoma, Amount and type of drainage, Clients response to the procedure

The nurse is performing nasotracheal suctioning of a client. What should the nurse do when suctioning this client?

Apply suction for 5-10 seconds

The nurse is preparing to administer a feeding to a client with a gastrostomy tube. What should the nurse do before providing this feeding?

Assess tube placement

The nurse has completed trach suctioning of a client. What should the nurse document about this procedure? SATA A- amount of sterile solution used to flush the catheter. B- amount, consistency, color, odor of sputum. C- lung sounds before the procedure. D- lung sounds after the procedure. E- oxygen saturation after the procedure.

B- amount, consistency, color, odor of sputum. C- lung sounds before the procedure. D- lung sounds after the procedure. E- oxygen saturation after the procedure.

A client's new onset of dysphagia has required insertion of an NG tube for feeding; the nurse has modified the client's care plan accordingly. What intervention should the nurse include in the client's plan of care?

Confirm placement of the tube prior to each scheduled feeding.

A client has just returned to the floor following a transurethral resection of the prostate. A triple-lumen indwelling urinary catheter has been inserted for continuous bladder irrigation. What, in addition to balloon inflation, are the functions of the three lumens?

Continuous inflow and outflow of irrigation solution

The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. Which next step will the nurse anticipate?

Debride the wound

A client is receiving the first of two prescribed units of PRBC's. Shortly after the initiation of the transfusion, the client reports chills and experiences a sharp increase in temperature. What is the nurse's priority action?

Discontinue the transfusion

A client's enternal feedings have been determined to be too concentrated based on the client's development of dumping syndrome. What physiologic phenomenon caused this client's complication of enteral feeding?

Entry of large amounts of water into the small intestine because of osmotic pressure

The nurse is preparing to insert a nasogastric tube in a patient who is semiconscious. To determine the length of the tube needed to be inserted, how should the nurse measure the tube?

From the tip of the nose to the earlobe to the xiphoid process. -'

As the nasogastric tube is passed into the oropharynx, the client begins to gag and cough. What is the correct nursing action?

Give the client a few sips of water.

The nurse should incorporate which instructions into the teaching plan for a client with a urinary diversion?

Increasing the fluid intake helps to flush out sediment and mucus and prevents clogging of the stoma

A nurse has performed tracheal suctioning on a client who experienced increasing dyspnea prior to a procedure. When applying the nursing process, how can the nurse best evaluate the outcomes of this intervention?

Measure the client's oxygen saturation

The nurse is completing an assessment of the patient's skin integrity. Which assessment is the priority?

Pressure points

Ostomies may be necessary for what reasons? SATA

Reasons a colostomy is done include: Infection of the abdomen, such as perforated diverticulitis or an abscess. Injury to the colon or rectum (for example, a gunshot wound). Partial or complete blockage of the large bowel (intestinal obstruction).

A nurse is caring for a client with a nasogastric tube for feeding. During shift assessment, the nurse auscultates a new onset of bilateral lung crackles and notes a respiratory rate of 30 breaths per minute. The client's oxygen saturation is 89% by pulse oximetry. After ensuring the client's immediate safety, what is the nurse's most appropriate action?

Report possible signs of aspiration pneumonia to the primary provider.

A nurse is writing a care plan for a client with a nasogastric tube in place for gastric decompression. Which risk nursing diagnosis is the most appropriate component of the care plan?

Risk for Impaired Skin Integrity Related to the Presence of NG Tube

A nurse is writing a care plan for a client with a nasogastric tube in place for gastric decompression. Which risk nursing diagnosis is the most appropriate component of the care plan?

Risk for impaired skin integrity related to the presence of NG tube.

When suctioning a patient, the patient should be placed in what position

Semi- fowlers

An elderly female client who is bedridden is admitted to the unit because of a pressure ulcer that can no longer be treated in a community setting. During assessment, the nurse finds that the ulcer extends into the muscle and bone. At what stage should the nurse document this ulcer?

Stage 4

Which type of binder would be utilized to provide support to a wound in the rectal or perineal area?

T- binder

The primary purpose of drains is

The main indications for drain use include the need to eliminate dead space, remove existing fluid or gas, and prevent accumulation of fluid or gas.

A PICC line inserted in the arm is a central venous catheter T/F

True

The nurse is preparing to administer 14 units of Regular insulin, as ordered by the physician. When gathering equipment, which syringe would be the most appropriate for use with medication to be administered?

U-100 insulin syringe, 30 unit capacity

The nurse is caring for a patient on contract precautions. Which action will be the most appropriate to prevent the spread of disease?

Use a dedicated blood pressure cuff that stays in the room and is used for that patient only.

To reduce patient discomfort during a closed intermittent catheter irrigation, what should the nurse do?

Use room temperature irrigation solution.

While caring for a client with a tracheostomy tube, the nurse should normally provide suctioning how often?

When adventitious breath sounds are auscultated

The name of the product that is used to decrease CLABSI is

biopatch

A client is rushed to the emergency department with what the physicians suspect to be necrosis of the urinary diversion stoma. What evidence presented by the client leads to this conclusion?

black with sloughing

The nurse rolls the insulin vial in the palms of the hands to

ensure consistent concentrations of the medication throughout the vial

The seal, or wafer, around a urostomy should be changed every 3-7 days

false

Parts of the tracheostomy tube include the SATA. flange, inner cannula, outer cannula, obturator, suction cannula

flange, inner cannula, outer cannula, obturator

Complication of tracheostomy suctioning include all except? A- healthcare-inquired infection. B- cardiac dysrhythmia. C- hypoxemia. D- hyperinsufflation.

hyperinsufflation

Patients should be placed in what position when having a fecal management system inserted?

left side lying position

Which insulins should never be mixed?

long-acting insulins

A nasogastric tube may be used for the following reasons except A-gastric decompression. B- long-term enteral nutrition. C- gastric lavage. D- short- term enteral nutrition

long-term enteral nutrition

The nurse should admit a client requiring airborne precautions into which of the following types of rooms?

negative pressure

The name of the correct method of flushing for central lines is

push stop

A patient with an ileostomy is losing weight. The patient asks the nurse why. The nurse's best response is to tell the patient that most enzymes and nutrients are absorbed in the

small intestine?

A client has a newly created tracheostomy for mechanical ventilation after a surgical procedure. What action should the nurse plan for this client?

tape the tracheostomy obturator to the head of the bed

A medical nurse is caring for a client with type 1 diabetes. The client's medication administration record includes the administration of regular insulin three times daily. Knowing that the client's lunch tray will arrive at 11:45 am, when should the nurse administer the client's insulin?

11:15

A medical nurse is caring for a client with type 1 diabetes. The client's medication administration record includes the administration of regular insulin three times daily. Knowing that the client's lunch tray will arrive at 11:45 AM, when should the nurse administer the client's insulin?

11:15 AM

The patient has a risk for skin impairment and has a 15 on the braden scale upon admission. The nurse has implemented interventions. Upon reassessment, which braden score will be the best sign that the risk for skin breakdown is removed? a. 12. b. 13. c. 20. d. 23

23

A penrose drain is usually

?? A Penrose drain is a soft, flat, flexible tube made of latex. It lets blood and other fluids move out of the area of your surgery. This keeps fluid from collecting under your incision (surgical cut) and causing infection. Part of your Penrose drain will be inside your body.Oct 8, 2019

A nurse is planning care for a group of patients. Which task will the nurse assign to the nursing assistive personnel?

Administering an enem

Which observation by the nurse best indicates that a continuous bladder irrigation for a patient following genitourinary surgery is effective?

Bright red urine turns pink in the tubing

In order for patients with a tracheostomy tube to speak, they must use a A- pessary. B- Pulmonic valve. C- Button. D- Obturator.

Button

The patient is to receive multiple medications via the nasogastric tube. /the nurse is concerned that the tube may become clogged. Which action is best for the nurse to take?

Check with the pharmacy for availability of the liquid form of medications

The nurse is collecting a specimen from an infected wound. From which portion of the wound should the specimen be collected?

Clean areas of granulation tissue

The nurse is caring for the stoma of a client who has a colostomy. Which action is the most appropriate?

Clean the stoma and pat dry

For an IV to be considered a central line, the tip must be in the inferior vena cava. T/F

False

It is acceptable to use same insulin pen for more than one patient if the pen is wiped down with an antiseptic between each use and a new needle is applied for each patient. T/F

False

Placing a label with the date, time, and your initials over the insertion site is an important step in the care of the central line. T/F

False

To help decrease the risk of complications, it is important to gently rotate the suction catheter as you withdraw it, and to never suction longer than 1-2 minutes. T/F

False

When suctioning a patient who has a tracheostomy tube, it's important to use sterile water. T/F

False

The nurse is performing care for a client with a new tracheostomy needs to change the ties. What is the best method for changing the ties?

Have an assistant hold the trach tube in place, remove the soiled ties, and replace the ties.

A nurse is preparing to place a clients prescribed nasogastric tube. What anticipatory guidance should the nurse provide to the client?

Insertion is likely to cause some gagging.

The nurse is caring for a patient who has cultured positive for Clostridium difficle. Which action will the nurse take next?

Instruct assistive personnel to use soap and water rather than sanitizer to clean hands

The nurse is caring for a patient who is at risk for skin impairment. The patient is able to sit up in a chair. The nurse includes this intervention in the plan of care. How long should the nurse schedule the patient to sit in the chair?

Less than 2 hours

Which action will the nurse take to reduce the risk of excoriation to the mucosal lining of the patient's nose from a nasogastric tube?

Lubricate the nares with water- soluble lubricant

The nurse is to administer four oral medications to the client via a nasogastric tube. One of the medications is a tablet that has to be crushed, one is a capsule that has been opened and the powder removed, and two are supplied in liquid form How should the nurse administer these medications?

Mix the crushed tablet and capsule powder individually in warm water. Administer each medication separately, flushing the tube before and after each administration.

The nurse is caring for a client with a urinary diversion. For which type of diversion should the nurse plan care for this client?

This is an incontinent urinary diversion (ileal conduit).

The proper suction regulator setting for tracheostomy tube suctioning is 80-100 mmHg intermittent suction. T/F

True

A patient has developed a pressure ulcer. Which laboratory data will be important for the nurse to check?

albumin

The nurse is discussing different types of ostomy appliances with a client with a new ostomy. During this discussion, the nurse should keep in mind that an ostomy appliance should do which of the following? SATA

protect the skin, collect stool., control odor.

All of the following sites can be used for insertion of a central line, except a- internal jugular. b- pulmonary. c- basillic. d- femoral.

pulmonary

After the maximum therapeutic effect of a thermal application has been achieved, the opposite effect may begin to occur. This is called the

rebound phenomenon

After the maximum therapeutic effect of a thermal application has been achieved, the opposite effect may begin to occur. This is called the

rebound phenomenon?

Sitz baths are a type of heat therapy designed to target what area of the body?

rectum/perineal?

A tracheostomy tube is placed through the neck and into the

trachea

The purpose of Montgomery straps is to hold bandages in place without using tape

true

A colostomy is a permanent diversion of stool through the abdominal wall.

true?

A common urinary diversion that creates a pouch and stoma is

urostomy

A small- bore feeding tube is placed. Which technique will the nurse use to best verify tube placement?

x-ray