Therapeutic Measures Review

A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of the following indications should the nurse include?

Relief of urinary retention, measurement of residual urine after urination, presence of an open perineal wound

A nurse is caring for a client whose hysterectomy wound eviscerated. Which of the following actions should the nurse take?

Cover the wound with a moist sterile dressing

A nurse is providing instructions regarding heat therapy to a client who has cellulitis of the leg. Which of the following statements by the client indicates the understanding of the therapy?

"Ill apply warm, moist compresses to my leg twice a day."

A nurse is reinforcing teaching about vancomycin with a client who has an infection. Which of the following information should the nurse include in the teaching?

"Notify your provider if you experience any changes in your hearing

A nurse is preparing to insert an indwelling urinary catheter for a female client. After opening the catheter kit and preparing the supplies, which of the following steps should the nurse perform next?

Don sterile gloves

A nurse is preparing to replace a client's abdominal dressing which is covering a large incision with a Penrose drain. Which of the following steps is appropriate for the nurse to take?

Donning clean gloves to remove the dressing

A nurse is collecting data from a client who has a urinary tract infection. Which of the following findings should the nurse expect?

Dysurua, urinary frequency, hematuria

A nurse is caring for a client receiving total parenteral nutrition (TPN) therapy via an infusion pump. When collecting data about the client receiving this therapy, which of the following observations by he nurse is critical?

IV insertion site

A nurse works in a long-term care facility which will be Goal of preventing health-care associated pressure ulcers. When educating assistive personnel about the new standard, the nurse emphasizes implementing new protocol to meet the Joint Commission's (JCAHO) National Safety that it is most important to:

Identify the residents at greatest risk for development of pressure ulcers

A nurse is collecting data from a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection?

Increase in neutrophils and localized edema

A nurse is contributing to the plan of care for a client who has COPD. Which of the following interventions should the nurse include in the plan of care?

Instruct the client to use pursed-lip breathing

The nurse is working with a client after surgery. What is the appropriate intervention by the nurse to prevent incisional infection?

Proper hand washing prior to dressing changes

A nurse is caring for a client who has pneumonia. The clients oxygen saturation is 85%. Which of the following should the nurse do first?

Raise the head of the bed

A nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. The nurse should monitor the client for which of the following expected outcomes after catheter removal?

Temporary urinary retention

A nurse is planning to insert an indwelling urinary catheter for an adult female client. Which of the following actions should the nurse plan to take?

lubricate the catheter 2.5*5 cm (1-2 in)

The nurse is caring for a client who has a large wound which has a vacuum-assisted closure device placed over it. Which of the following findings should alert the nurse to a possible wound infection?

musty odor from the foam dressing upon removal

A nurse is preparing to remove the urinary catheter. After preforming hand hygiene, which of the following actions should the nurse take?

position the client supine

A nurse is contributing to the plan of care for a client who has a pressure ulcer on his heel. Which of the following should the nurse include in the planning?

provide the client a diet high in vitamin c

A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse suspects the clients wound is infected because of the draining from the dressing is yellow and thick. Which of the following findings should the nurse report as the type of drainage found?

purulent

A nurse is planning preventative care for a client who has pressure ulcers and is confined to bed. Which of the following is an appropriate nursing action?

reposition the client every 2 hours

A nurse is providing care to a client who has COPD and is receiving supplemental oxygen. Which of the following findings should the nurse report to the RN immediately?

speaks in short phrases

A nurse is caring for a client who is receiving heat applications using aquathermia pad. Which of the following actions should the nurse take when applying the pad?

stop the treatment if the clients skin becomes red

A nurse is caring for a client who has a wound. The nurse should recognize that which of the following findings is indicative of a wound infection?

swelling and tenderness around the wound

A nurse is assisting with speaking in front of a large group of nurses about new guild lines to prevent pressure ulcers. Which of the following action by the nurse demonstrates confidence?

the nurse stands tall efore talking

A nurse is caring for a client who has a large surgical wound healing by secondary intention. The nurse should recommend a diet high in protein and?

vitamin c

A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in his surgical incision. The nurse checks the clients surgical wound and finds evisceration. Which of the following interventions is appropriate?

Cover the area with saline-soaked sterile dressings

A nurse is caring for a client diagnosed with congestive heart failure who experiences respiratory arrest. Which of the following the the first action the nurse should take?

establish an open airway

Which of the following should the nurse recognize as a sign of possible infection in a postoperative client?

adventitious breath sounds, decreased level of consciousness, and oral temp of of 101

A nurse is assisting with the preparation of a presentation at a community center about complementary and alternative therapies. Which of the following therapies should the nurse describe as the use of an electronic monitoring device to help clients learn to control physical responses?

biofeedback

A nurse is caring for a client receiving IV therapy in the left forearm and notices that the site is red, swollen, and has fluid weeping from surrounding tissues. Which of the following actions should the nurse perform first?

discontinue the existing IV line

A nurse is preparing a client for ambulatory surgery. After the nurse places an IV line, the client reports that the IV is painful. Which of the following actions should the nurse take?

Attempt to reinsert an IV into a new site

A nurse is contributing to the care plan of an older adult client who has pneumonia. Which of the following interventions should the nurse include in the plan?

Encourage fluid intake of 2.5L per day

A nurse is caring for a client who has pneumonia and is coughing up secretions. Which of the following actions should the nurse take first?

Encourage the client to cough and deep breathe

A nurse is caring for a client who has COPD. Which of the following actions should the nurse take?

Encourage the client to drink 8 glasses of water a day

A nurse is caring for a client who had abdominal surgery 2 days ago. Which of the following observations requires an intervention by the nurse?

Thick, yellow-green drainage on wound

A nurse in an emergency department is caring for a client who has a deep laceration on her left lower forearm and is bleeding heavily from the wound. Which of the following interventions should the nurse perform next?

apply pressure directly to the wound

When replacing a clients dressing, the nurse observes that the wound surface is covered with soft, pink tissue that bleeds easily. The nurse should document the presence of which of the following?

granulation tissue

A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound drainage specimen for culture?

cleanse the wound with 0.9% sodium chloride irrigation before obtaining the specimen

A nurse notes a small section of bowl protruding from the abdominal incision of the postoperative client. Which of the following actions should the nurse preform first?

cover the patients wound with a most sterile dressing

A nurse is caring for a client who has pneumonia and has been receiving oxygen therapy for several days. When collecting data from the client, the nurse should identify which of the following finding as an indication of an adverse effect of oxygen therapy?

cracks in oral mucous membranes

A nurse is preparing to measure a clients level of oxygen saturation and notes edema of both of the clients hands and thickened toe nails. The nurse should apply the pulse oximeter probe to which of the following locations?

earlobe

A nurse is changing the dressing on a clients wound. The nurse should recognize that which of the following findings is an indication of a wound infection?

edema

A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to thin the clients respiratory secretions?

encourage the client to drink more fluids

A provider is discharging a client with a prescription for home oxygen therapy. Reinforcement of client and family teaching by the nurse should include which of the following interventions?

ensure that the straps on the mask are secure but not too tight, check the tops of the ears regularly for skin breakdown, post "no smoking" warning signs at home in a prominent location

A nurse is assisting with the care of a client who is receiving continuous IV therapy. The nurse is observing the IV site. Which of the following manifestations indicated that the client has developed phlebitis?

erythema

A nurse is caring for a client following the application of an aquathermia pad. Which of the following is the first indication that the client is experiencing a thermal injury to the application site?

erythema

A home health nurse is visiting a client who has COPD and is receiving oxygen at 2L/min via nasal cannula. The client tells the nurse she has been having difficultly breathing. Which of the following actions is the nurses priority at this time?

evaluate the patients respiratory status

A nurse is caring for a female client who has prescription for an indwelling urinary catheter. Which of following actions should the nurse take first?

explain to the client that she will feel temporary discomfort