BSN206

A nurse assists a patient with a Foley catheter to ambulate down the hall. The nurse holds the catheter bag below the level of the patient s bladder. What link in the chain of infection is the nurse breaking by doing so? Portal of exit. Portal of entry. Reservoir. Host susceptibility.

Portal of entry

Which of the following would be inappropriate to delegate to NAP? Pouching a newly established ostomy. Administering a tap water enema. Administering a Fleet-type enema (commercially prepared). Recording the amount of ostomy output.

Pouching a newly established ostomy

A patient states that she is unable to get her transparent dressing to stay in place. What instruction should the nurse provide the patient? "If you are having difficulty with your dressing changes, we can see if the doctor will give you a referral to a home care agency." "Make sure that you have a margin of 1 to 1.5 inches (2.5 to 3.75 cm) around the wound, and that the skin is thoroughly dry before applying the dressing." "This type of dressing requires frequent changing because they do not stay in place." "You probably are applying it incorrectly, or perhaps you are just too anxious about having to perform the dressing change." "There are many options on the market. Why don't you try to use a non-adhesive-backed transparent dressing instead?"

Make sure that you have a margin of 1 to 1.5 inches (2.5 to 3.75cm) around the wound, and that the skin is thoroughly dry before applying the dressing

A patient is being given a bed bath. The nurse realizes that another washcloth is needed to complete the bath. What is one way in which the nurse can ensure the patient's safety? Use the call light to ask someone else to bring a washcloth. Raise the bed to its highest position. Raise all four side rails on the patient's bed. Make sure the call light is within the patient's reach.

Make sure the call light is within the patient's reach

Identify interventions for irritation around the stoma. (Select all that apply.) Make sure there is a good seal of the skin barrier/pouching system so that undermining of fecal contents will be avoided. Remove the pouch more quickly. Determine whether the patient's skin is reacting to adhesive removal. Consult the ostomy care nurse. Determine whether a different type of pouching system is needed to prevent leakage.

Make sure there is a good seal of the skin barrier/pouching system so that undermining of fecal contents will be avoided Determine whether the patient's skin is reacting to adhesive removal Consult the ostomy care nurse Determine whether a different type of pouching system is needed to prevent leakage

The patient complains "It feels like the drain is pulling on my surgical site." What is the nurse's best action? Secure the drain above the incision to the dressing with tape and a safety pin and instruct the patient to keep the drain above the insertion site when ambulating, sitting, and lying. Correct! Make sure there is slack in the tubing from the reservoir to the wound, allowing the patient movement and avoiding pulling at the insertion site. Instruct the patient that this is the normal sensation of having a drain. Have the patient lie down and advance the drain further into the patient until the sensation is relieved and drainage is noted in tubing; secure a new dressing over insertion site of drain.

Make sure there is slack in the tubing from the reservoir to the wound, allowing the patient movement and avoiding pulling at the insertion site

Identify contributing factors to pressure injury formation. (Select all that apply.) Malnutrition. Middle age. Decreased sensory perception/mobility. Anemia. Excessive sweating. Ethnic background.

Malnutrition Decreased sensory perception/mobility Anemia Excessive sweating

A patient is to have frequent dressing changes. What should the nurse use to secure the dressing? Adhesive tape. Paper tape. Hypoallergenic tape. Montgomery ties.

Montgomery ties

A patient asks the nurse why the Montgomery ties are being used instead of regular tape. What is the nurse's best response? "Because Montgomery ties are nonallergenic." "Montgomery ties can be tied tighter, providing a more secure dressing and greater support of the wound." "Montgomery ties allow the wound to breathe." "Montgomery ties avoid frequent removal of tape, which is irritating to the skin during dressing changes."

Montgomery ties avoid frequent removal of tape, which is irritating to the skin during dressing changes

Which of the following should NOT be delegated to nursing assistive personnel (NAP)? Oropharyngeal suctioning. Nasotracheal suctioning. Pulse oximetry. Oral care.

Nasotracheal suctioning

Which of the following is considered a sterile procedure and therefore requires sterile gloves? None of the above. Preparing a soap suds enema for administration. Administering a cleansing enema. Pouching an ostomy.

None of the above

An infant is to have an enema. Which solution would the nurse anticipate using? Fleet (hypertonic) solution. Tap water enema. Castile soap and tap water. Normal saline.

Normal saline

A new quality assurance program has been instituted on the unit because of a higher than average infection rate. Which of the following could be factors responsible for this increase? (Select all that apply.) Nurse D has fingernails less than ¼ inch long. Nurse F has chipped nail polish. Nurse B performs hand hygiene between patients. Nurse E has open cuts on her hand. Nurse A wears artificial nails.

Nurse F has chipped nail polish Nurse E has open cuts on her hand Nurse A wears artificial nails

What would be the nurse's priority in order to minimize a patient's risk for injury during oxygen therapy? Monitoring the patient for signs of hypoxia. Observing the six rights of medication administration. Instructing nursing assistive personnel (NAP) to immediately correct the flow rate if the oxygen regulator is not set as prescribed. Advising the patient to call for assistance before getting out of bed.

Observing the six rights of medication administration

A patient has removed her dentures and placed them on the bedside stand. What would the nurse do to protect the patient's dentures? Wrap the dentures in a paper towel. Obtain a denture cup, label it with the patient's name, and store the dentures in a safe place. Store the dentures in the patient's bedside stand, and notify other staff of where they have been placed. Wrap the dentures in a damp washcloth, and place them in a denture cup.

Obtain a denture cup, label it with the patient's name, and store the dentures in a safe place

During application of the condom catheter, the adhesive strip falls to the floor. What is the nurse's best action? Obtain silk tape because it has some ability to stretch. Use paper tape in a spiral fashion because it is nonallergenic. Use plastic IV tape because it is waterproof preventing slippage. Obtain another adhesive strip from condom catheter kit.

Obtain another adhesive strip from condom catheter kit

The nursing instructor is asking the nursing students to share their knowledge regarding sterile gloving. Which statement, if made by a student, would require correction? Be sure to select appropriate size gloves. Gloves that are too small can tear more easily. Once sterile gloves are applied, the inside of the glove is still considered sterile. Be sure to select appropriate size gloves. Gloves that are too large can impede your ability to pick up items and perform your task. If you touch a nonsterile item with your sterile gloved hands, you should remove the gloves and obtain a new pair.

Once sterile gloved are applied, the inside of the glove is still considered sterile

The nurse is preparing a sterile field. The nurse opens the sterile commercial kit by pulling the outermost flap toward his body, followed by opening the remaining flaps. The nurse touches only the outer edge of the sterile field with his hands. The nurse adds sterile items to the sterile field by placing them on the field at an angle and never allowing the wrapper to touch the field. The nurse pours normal saline form a previously opened bottle in the patient's room into a sterile receptacle without splashing. Which action(s) in preparing a sterile field did the nurse perform incorrectly? (Select all that apply.) The nurse correctly prepared the sterile field. Opening the outermost flap. Touching the outer edge of the sterile field. Adding sterile items to the field. Pouring a sterile solution.

Opening the outermost flap Pouring a sterile solution

As part of catheter insertion assessment, where should the nurse palpate? At the costovertebral angle. Above the symphysis pubis. Starting at the right iliac crest and moving upward along the midclavicular line. Midway between the xyphoid process and symphysis pubis.

Above the symphysis pubis

The nurse has received an order to insert an indwelling catheter in a 24-year-old female patient. Which catheter would be most appropriate for this patient? 16 Fr 30 mL balloon 10 Fr 3 mL balloon 20 Fr 5 mL balloon 14 Fr 5 mL balloon

14 Fr 5 mL balloon

A 15-year-old male patient is hypothermic. Which temperature reflects hypothermia? 99° F (37.2°C). 95° F (35°C). 110° F (43.3°C). 101° F (38.3°C).

95F (35C)

The nurse is monitoring the patient for a possible vagal response while removing a fecal impaction. If the patient had a vagal response, what would the nurse most likely observe? Tachycardia. Hypertension. A decrease in heart rate. A decrease in respirations.

A decrease in heart rate

What will the nurse do first when preparing to apply personal protective equipment (PPE) before caring for a patient in isolation? Perform hand hygiene Apply eyewear Put on clean gloves Put on the gown

Perform hand hygiene

Which of the following is the best example of documentation of enema administration? 0800 1000 mL tap water enema administered without difficulty. Moderate return of soft formed brown stool. 1000 Soap suds enema administered. Patient tolerated well. 0830 800 mL tap water enema administered. Return clear with no fecal material Bowel sounds present in all 4 quadrants pre and post procedure. Abdomen nondistended. Patient states "I'm glad that's over." 0900 1000 mL warmed tap water with 5 mL castile soap enema administered per health care provider's order. Patient instructed not to flush toilet. Patient held enema solution approximately 5 minutes. Good return. Patient repositioned for comfort. Call light in reach.

0830 800 mL tap water enema administered. Return clear with no fecal material Bowel sounds present in all 4 quadrants and post procedure. Abdomen nondistended. Patient stated "I'm, glad that's over"

Which of the following patients has the least risk for developing a wound infection? An 80-year-old man who has a burn. A 17-year-old patient who has a metal fragment lodged in his thigh. 30-year-old woman who had an episiotomy with childbirth. A patient receiving chemotherapy who has a surgical incision. A patient with peripheral vascular disease and an ulcer on the heel.

A 30-year-old woman who had an episiotomy with childbirth

Which of the following patients would have the greatest potential for an alteration in respiration? A 15-year-old boy with a migraine headache. A 44-year-old woman with anemia. A 19-year-old woman with diarrhea. A 32-year-old man with an earache.

A 44-year-old woman with anemia

An adult patient is scheduled for an abdominal computed tomography (CT) scan. Before the scan he must receive a cleansing tap water enema. The nurse should prepare: At least 2000 mL of tap water. Correct! 1000 mL or less of tap water. 5 mL of castile soap and 1500 mL of water. 180 mL of prepackaged (Fleet) enema solution.

1000 mL or less of tap water

A 68-year-old female patient is admitted for knee replacement surgery with an expected hospital stay of 2 weeks. She has no known allergies. The health care provider has ordered an indwelling catheter to be inserted preoperatively. Which catheter should the nurse choose? 14 French, 5-mL balloon, latex catheter. 18 French, 5-mL balloon, latex catheter. 8 French, 3-mL balloon, latex catheter. 16 French, 30-mL balloon, silicon catheter.

14 French, 5-ml balloon, latex catheter

If a patient's indwelling catheter is removed at 0900, the patient should be due to void by: 1900 to 2100 (7:00 PM to 9:00 PM) 1100 to 1200 (11:00 AM to 12:00 PM) 1500 to 1700 (3:00 PM to 5:00 PM) 0930 (9:30 AM)

1500 to 1700 (3:00 PM to 5:00 PM)

A 40-year-old male patient has been admitted for abdominal surgery. He has no history of prostate problems. The health care provider has ordered that the patient be catheterized. Which of the following would be an appropriate-size catheter for this patient? 8 French, 3-mL balloon 12 French, 5-mL balloon 16 French, 5-mL balloon 16 French, 30-mL balloon

16 French, 5-ml balloon

What would the nurse do when receiving an order to increase the delivery rate of a patient's oxygen per nasal cannula from 1 L/min to 3 L/min? Change the device from nasal cannula to simple face mask Encourage the patient to take deeper breaths in order to get more oxygen Adjust the float ball on the flow meter to 3 L/min Ensure that humidification is present

Adjust the float ball on the flow meter to 3 L/min

The nurse is orienting a new graduate nurse to common procedures performed on the unit. Which statement, if made by the graduate nurse, indicates understanding of nasotracheal suctioning? "The maximum duration to suction is 20 seconds." "The bacterial count in the nasotracheal pathway is higher, therefore suction the trachea through the mouth." "A 1- to 2- minute interval should be allowed between suctioning passes." "Intermittent suction is applied during insertion of the catheter."

A 1- to 2- minute interval should be allowed between suctioning passes

Which of the following patients would be expected to benefit from a damp-to-dry dressing? (Select all that apply.) A 24-year-old patient with an open and infected wound from a spider bite. A 7-year-old with abrasions on the knees. A 50-year-old with a postoperative knee-replacement incision. A 30-year-old after large cyst removal with necrotic tissue present in crater-type wound. A 19-year-old with a superficial laceration on the arm.

A 24-year-old patient with an open and infected wound from a spider bite A 30-year-old after large cyst removal with necrotic tissue present in crater-type wound

Which of the following would be considered a normal finding after the administration and evacuation of an enema? The patient complains of a firm and painful abdomen. High-pitched, hyperactive bowel sounds are present. Abdominal distention is absent. The patient passes approximately 50 mL of bright red blood.

Abdominal distention is absent

Which of the following patients is at greatest risk for developing a wound infection? A diabetic obese patient who smokes. An adolescent who takes steroids for asthma. An elderly patient. An alcoholic.

A diabetic obese patient who smokes

Which of the following is an example of healing by secondary intention? (Select all that apply.) A dog bite. A burn. A skin tear. A full-thickness pressure injury. A surgical incision.

A dog bite A burn A full-thickness pressure injury

Which of the following would lead to an increase in oxygen demand? A fever. Sleep. Taking a narcotic. Postural drainage.

A fever

A patient was hospitalized for surgical repair of a fractured hip. Upon admission her lungs were clear to auscultation and she was afebrile. Her discharge was delayed because she developed a fever and respiratory distress. A chest x-ray confirmed left lower lobe pneumonia. Which type of infection best describes what this patient has? A health care-associated infection. A systemic infection. A drug-resistant infection. A local infection.

A health-care associated infection

Nursing assistive personnel (NAP) reports the patient's stoma appears purple. What would likely be the cause? A lack of circulation to the stoma. The patient ate something purple. The patient has been exercising vigorously. Nothing, this is a normal finding.

A lack of circulation to the stoma

The nurse is reading electronic documentation from the emergency room on a patient who is to be admitted to the unit. The documentation states that the patient has a hematoma on the right knee. What does the nurse expect to see? A localized collection of blood underneath the tissues that often takes on a bluish discoloration. An area of skin that has been scraped away. A shallow wound with loss of the epidermis and partial loss of the dermis. A deep wound extending into the dermis.

A localized collection of blood underneath the tissues that often takes on a bluish discoloration

The nurse works on a surgical unit. For which of the following patients would a nurse expect to perform a bladder scan? (Select all that apply.) A patient who had an indwelling urinary catheter removed 8 hours ago and voided 30 mL once since it was removed. A patient who complains she is having urinary incontinence and never had this problem before. A patient who is postoperative for urological surgery. A patient who was placed on diuretic therapy to reduce peripheral edema. A patient who reports a change in urine color.

A patient who had an indwelling urinary catheter removed or 8 hours ago and voided 30 mL once since it was removed A patient who complains she is having urinary incontinence and never had this problem before A patient who is postoperative for urological surgery

Which of the following patients may likely require oropharyngeal suctioning? (Select all that apply.) A patient who had maxillofacial surgery. A patient who had trauma to the mouth. A patient with impaired swallowing from neurological injury. A patient who has been diagnosed with lung cancer. A patient with an artificial airway who requires oral hygiene. A patient who has a nasogastric feeding tube.

A patient who had maxillofacial surgery A patient who had trauma to the mouth A patient with impaired swallowing from neurological injury A patient with an artificial airway who requires oral hygiene

To which of the following patients would it be considered acceptable to administer an enema without the nurse needing to question the order? A patient who is going to have abdominal surgery. A patient with glaucoma. A patient with inflammatory bowel disease. A patient with increased intracranial pressure.

A patient who is going to have abdominal surgery

Four patients had a bladder scan for PVR. For which of the following patients would further investigation be required? A patient with a PVR of 25 mL. A patient with PVR measurements of 125 mL and 150 mL. A patient with a PVR of 50 mL. A patient with a prescan volume of 250 mL and a PVR volume of 30 mL.

A patient with PVR measurements of 125 mL and 150 mL

Which patient should not have his or her feet soaked during a complete bed bath? A patient who is nauseated A patient with diabetes mellitus A patient with arthritis A patient who has just complained of shoulder pain

A patient with diabetes mellitus

Which of the following could be considered negligence? A regular condom catheter is removed every 3 days. Clean gloves are worn to apply a condom catheter. Allowing a family caregiver to apply the condom catheter. Avoiding the use of barrier creams on the penile shaft.

A regular condom catheter is removed every 3 days

Which of the following is a potential complication for a patient who is having nasotracheal suctioning? (Select all that apply.) Correct! A significant drop in oxygen concentration. Correct! A decrease in heart rate. Dysrhythmias. Coughing during and after suctioning Less secretions in the airway.

A significant drop in oxygen concentration A decrease in heart rate Dysrhythmias

A small group of nursing students is giving a teaching presentation on the principles of surgical asepsis. Which of the following standards are appropriate to include in the presentation? (Select all that apply.) A sterile barrier that has been permeated by moisture must be considered contaminated. A sterile object or field out of the range of vision or an object held below a person's waist is considered contaminated. A sterile field or object cannot become contaminated by air. If there is any doubt about an item's sterility, the item is considered to be unsterile. All items used within a sterile field must be sterile.

A sterile barrier that has been permeated by moisture must be considered contaminated A sterile object or field out of the range of vision or an object held below a person's waist is considered contaminated If there is any doubt about an item's sterility, the item is considered to be unsterile All items used within a sterile field must be sterile

A patient is to receive enemas "until clear." The nurse notes that stool remains in the fecal return after the second enema. What should the nurse do? Notify the health care provider. Stop, as too many large-volume enemas can cause a fluid and electrolyte imbalance. Administer a third enema. Add castile soap to the next enema solution.

Administer a third enema

A nurse inserting an indwelling urinary catheter in a female patient advances the catheter and obtains clear yellow urine. What is the next action the nurse should take? Inflate the balloon with the prefilled syringe of sterile water in the balloon port. Pull gently back on the catheter approximately 1 inch or until resistance is met. Advance catheter another 1 to 2 inches and inflate balloon. Ask patient to bear down as if to void.

Advance catheter another 1 to 2 inches and inflate balloon

A patient tells the nurse that at home he cleans his dentures after every meal and before going to bed. When would denture care be planned for this patient while hospitalized? After breakfast and before going to bed With morning care After every meal and before going to bed With morning and evening care

After every meal and before going to bed

During a sterile dressing change, when are the gloves changed? After the old dressing is removed and before creating a sterile field. After the old dressing is removed and before cleansing the wound. After the old dressing is removed, after cleansing the wound, and before applying a new dressing. It is unnecessary to change gloves for chronic wounds.

After the old dressing is removed and before cleansing the wound

Which of the following are true regarding the impact of aging related to urinary elimination? (Select all that apply.) The elderly are better able to concentrate urine than the middle-aged adult. Aging can affect continence if the patient experiences impaired mobility or decreased muscle tone. The elderly are less likely to experience urinary frequency than middle-aged adults because they tend to drink less. The elderly are at increased risk for urinary tract infection because of retained urine in the bladder. It is part of the normal aging process for elderly patients to become incontinent.

Aging can affect continence if the patient experiences impaired mobility or decreased muscle tone The elderly are at increased risk for urinary tract infection because of retained urine in the bladder

A nursing instructor is reviewing medical asepsis with a group of nursing students. Which comment, if made by a student, indicates that further teaching is needed? "Alcohol-based hand rubs should be used often when caring for patients with Clostridium difficile." "Reducing the number of organisms and preventing their transfer is the goal of medical asepsis." "Performing hand hygiene is an example of breaking the transmission link in the chain of infection." "Health care-associated infections are most likely to develop in the urinary and respiratory tract."

Alcohol-based hand rubs should be used often when caring for patients with Clostridium difficile

The nurse is catheterizing a female patient and obtains a clear amber urine return. As the nurse begins to inflate the balloon, the patient complains of pain and resistance is felt. What is the nurse's best action? Allow fluid to flow back into syringe and advance the catheter a little more before attempting to reinflate. Have the patient take slow deep breaths, inhaling through the nose and exhaling through the mouth. Lift penis to position perpendicular to patient's body, and apply light traction. Advance catheter to bifurcation of the drainage tube and balloon inflation port.

Allow fluid to flow back into syringe and advance the catheter a little more before attempting to reinflate

Which of the following demonstrate that further teaching is required to prevent an infection related to being catheterized? (Select all that apply.) An elderly female patient carries her urinary drainage bag like a purse under her arm as she ambulates. A patient drinks an entire pitcher of water over the period of 1 day. As a patient is being transferred in a wheelchair, he places the drainage bag in his lap. The NAP places a patient's drainage bag on a lowered side rail or on the floor. A female patient keeps her catheter secured to her thigh with tape.

An elderly female patient carries her urinary drainage bag like a purse under her arm as she ambulates As a patient is being transferred in a wheelchair, he places the drainage bag in his lap The NAP places a patient's drainage bag on a lowered side rail or on the floor

A male patient with back and lower abdominal injuries from a motor vehicle accident is unable to void. His health care provider has ordered the insertion of a catheter to determine the amount of residual urine and then to remain in place to assist him with voiding during this post-trauma period. What type of urinary catheter should the nurse anticipate using? An indwelling catheter A Coudé catheter A condom catheter A straight catheter

An indwelling catheter

An elderly woman is hospitalized with pneumonia and anemia and has a history of heart failure. She is weak and has a poor cough effort. Her current vital signs are temperature 100.2 °F (37.9 °C), pulse 114, respiration 26, blood pressure 106/58. She has oxygen ordered at 2 liters by nasal cannula. Her oxygen saturation measures 88% when on room air, 93% with supplemental oxygen. She develops shortness of breath on any activity and eats little because it is difficult for her to eat and breathe at the same time. Which of the following are risk factors for this patient developing hypoxia? (Select all that apply.) Anemia. Tachycardia. Increased secretions with weak cough. Impaired cardiac function. Shortness of breath. Pneumonia.

Anemia Increased secretions with weak cough Impaired cardiac function Pneumonia

What does a goniometer measure? Muscle strength Angles of extension and flexion Joint stability Cranial nerve function

Angles of extension and flexion

The nurse is assessing the patient's condom catheter. Which of the following most likely indicates the condom catheter should be removed? Patient complains of the leg bag feeling "heavy" while in bed. Redness and/or excoriation of the penis Patient's urine appears clear amber with ammonia smell. Less than 30 mL/hr of urinary output.

Redness and/or excoriation of the penis

What can the nurse do to evaluate a patient's response to continuous oxygen therapy delivered at 4 L/min by nasal cannula? Evaluate venous blood levels every morning. Assess the patient for compliance with the prescribed therapy. Monitor the patient's arterial blood gas (ABG) levels hourly. Regularly measure and trend the patient's pulse oximetry (SpO2) values.

Regularly measure and trend the patient's pulse oximetry (SpO2) values

What would the nurse do first when preparing to educate the patient about safe administration of oxygen therapy at home? Arrange for a capable family member to be present during the initial discussion. Assess the patient's emotional readiness and physical ability to provide autonomous care. Collect written information to present to the patient as supplemental instructional materials. Evaluate the patient's understanding of the combustible nature of oxygen.

Assess the patient's emotional readiness and physical ability to provide autonomous care

When preparing to safely transfer a patient from a bed to a wheelchair using a transfer belt, the nurse would do what first? Assess the patient's physiological capacity to transfer. Determine whether to transfer the patient to a wheelchair or chair. Assess the patient's vital signs. Coordinate extra help.

Assess the patient's physiological capacity to transfer

The nurse has just helped a patient into the bathtub. Before leaving the bathroom, what would the nurse do to help ensure the patient's safety? Place an "Occupied" sign on the door. Show him how to use the call signal. Check the cleanliness of the room. Remove unneeded supplies from the bathroom.

Show him how to use the call signal

The NAP reports to the nurse the patient's respirations are 32 and the patient is complaining of shortness of breath. What is the best action by the nurse at this time? Request the NAP obtain the patient's pulse oximetry and report back. Ask the NAP to obtain and document a full set of vital signs. Assess the patient, including the pulse oximetry reading. Notify the health care provider of this change in condition.

Assess the patient, including the pulse oximetry reading

Which of the following are symptoms of latex allergy? (Select all that apply.) Skin redness. Itching. Purulent drainage. Edema. Difficulty breathing. Elevated temperature.

Skin redness Itching Edema Difficulty breathing

When caring for a patient who is receiving oxygen by simple face mask, which action ensures that the rate of oxygen being delivered is appropriate? Ensuring that the oxygen tubing is pulled tight, with little or no slack. Assessing for proper placement of the mask on the patient's face. Securing the oxygen tubing to the patient's clothing to prevent tugging. Frequently asking the patient how he or she is breathing.

Assessing for proper placement of the mask on the patient's face

When caring for a patient for whom oxygen by nonrebreathing mask has been ordered, which action ensures appropriate oxygen delivery? Looping the oxygen tubing around the side rail of the bed Securing the tubing snugly to the patient's gown Assessing breath sounds every shift Assessing that the reservoir bag stays inflated

Assessing that the reservoir bag stays inflated

Which of the following lab results or measurements indicate a risk for impaired wound healing? (Select all that apply.) A white blood cell count of 7000 per mm3 (normal) Fasting blood glucose of 215 mg/dl (elevated) A hemoglobin of 10.0 g per dL (decreased) A BMI (body mass index) of 35 (elevated) A serum albumin of 2.9 g/dl (decreased)

Fasting blood glucose of 215mg/dl (elevated) A hemoglobin of 10.0 g per dL (decreased) A BMI (body mass index) of 35 (elevated) A serum albumin of 2.9 g/dl (decreased)

When caring for a patient receiving oxygen by nasal cannula, which of the following is a priority to help maintain good skin integrity? Frequently applying moisturizing lotion to facial areas that come into contact with the cannula. Instructing the patient to inform staff of any problems with facial dryness or cracking. Removing the cannula every 2 hours for no longer than 10 minutes. Assessing the patient's external ears, nares, and nasal mucosa for breakdown at least once per shift.

Assessing the patient's external ears, nares, and nasal mucosa for breakdown at least once per shift

When preparing to provide mouth care to a patient who is in a coma, the nurse first ensures patient safety by doing what? Placing the bed in a flat position Inspecting the patient's oral cavity Connecting the suction equipment Assessing the patient's gag reflex

Assessing the patient's gag reflex

Which of the following are symptoms of a systemic infection? (Select all that apply.) Pain or tenderness. Fatigue. Fever. Redness. Edema. Nausea and vomiting.

Fatigue Fever Nausea and vomiting

Which of the following is inappropriate to delegate to nursing assistive personnel (NAP)? Emptying a closed drainage container. Measuring the amount of drainage. Assessment of wound drainage. Reporting the amount on the patient's intake and output record.

Assessment of wound drainage

Because a patient has a Penrose drain, the nurse inspects the patient's skin and changes the dressing by placing a drainage sponge around the drain. What is the rationale for doing this? Because drainage can be irritating to the skin and may cause skin breakdown. Because a Penrose drain has to be frequently compressed to create a constant low-pressure suction. To prevent the tubing from migrating into the wound. To advance the tube as the wound heals.

Because drainage can be irritating to the skin and may cause skin breakdown

An increase in venous pressure caused by liver disease can result in the development of: Hemorrhoids. Flatulence. Impaction. Diarrhea.

Hemorrhoids

A patient is to go home with a Jackson-Pratt drain. Which of the following statements, if made by the patient, indicates further teaching is required? "I should empty the drain when it is one-half to two-thirds full." "I should keep a record of how much drainage I empty." "If drainage suddenly stops, it means the drain is ready to be removed." "The bulb of the drain should remain compressed."

If drainage suddenly stops, it means the drain is ready to be removed

A patient has been transferred to a wheelchair with a transfer belt. What is one action the nurse would take to position the patient safely in the chair? Lower the foot rests, and place the patient's feet on them. Remove the transfer belt. Remove the wheelchair leg rests. Ask the patient to rate his or her pain level.

Lower the foot rests, and place the patient's feet on them

The patient is complaining of cramping during instillation of the enema solution. What is the most appropriate action by the nurse? Stop the instillation and remove the tube from the rectum. Lower the height of the enema container or clamp the tubing. Raise the height of the enema container. Have the patient take deep breaths in and out through the nose.

Lower the height of the enema container or clamp the tubing

The nurse is teaching the spouse of a patient how to perform oral suctioning for when they return home. Which of the following statements, if made by the spouse, indicates further instruction is needed? "It would be abnormal to obtain bloody secretions." "Because oral secretions are thick, suction settings should always be set on high." "I should be careful to avoid touching the back of the throat with the tip of the suction catheter." "I should encourage fluids to help keep secretions thin."

Because oral secretions are thick, suction settings should always be set on high

When should you perform hand hygiene? (Select all that apply.) Before applying gloves to insert an IV. After documenting in the patient's electronic medical record. After moving a patient up in bed. Before assessing a patient's vital signs. Before touching clean linens.

Before applying gloves to insert an IV After moving a patient up in bed Before assessing a patient's vital signs

The nurse is preparing to administer an enema. How can the nurse best facilitate insertion of the rectal tube? Place the patient in a side-lying position with the right knee flexed. Lubricate the first 6 to 8 cm (2.5 to 3 inches) of the tip of the tube. Hold the tube in the rectum until all of the fluid has been instilled. Flush the tube with the solution

Lubricate the first 6 to 8 cm (2.5 to 3 inches) of the tip of the tube

The nurse is assisting the NAP to remove an indwelling catheter. The nurse should intervene if which of the following actions is noted? The NAP: cleans the patient's perineal area, hands the patient their call light, and removes gloves. explains the procedure to the patient, regardless of condition or level of awareness. connects an empty syringe to the balloon port and allows it to fill passively. makes sure the balloon is completely deflated before removing the indwelling catheter.

Cleans the patient's perineal area, hand the patient their call light, and removes gloves

Which of the following is a method of wound debridement? Transparent dressing. Hemovac drain. Gauze dressing. Damp-to-dry dressing.

Damp-To-Dry dressing

What would the nurse instruct nursing assistive personnel (NAP) to report when performing denture care for a patient? The appearance of any cracks in the dentures The amount of time it takes to clean the patient's dentures Whether the patient uses mouthwash Any dietary preferences of the patient that could affect the teeth

The appearance of any cracks in the dentures

A patient with left-sided muscle weakness is prescribed a bath every other day. Which precaution would help the nurse reduce this patient's risk of falling? Maintain the water temperature at 104o F. Discuss the patient's level of fatigue after the bath. Allow the patient to remain in the bath for 45 minutes. Decline the patient's request to add scented oil to the bathwater.

Decline the patient's request to add scented oil to the bathwater

To apply sterile gloves, the nurse applied the first glove on the right hand. Where should the nurse pick up the remaining glove? Underneath the second glove's cuff. At the top edge of the cuff. You should pick it up with your ungloved hand. Anywhere, because the entire glove is sterile.

Underneath the second glove's cuff

Application of a condom catheter Insertion of an indwelling catheter Care of an indwelling catheter Insertion of a straight catheter Perform a bladder scan

Application of a condom catheter Care of an indwelling catheter Perform a bladder scan

The nurse performs nasotracheal suctioning. Which of the following is an incorrect sequence for this procedure? Apply sterile gloves, pick up the suction catheter with dominant hand, secure the catheter to the tubing, connect the tubing to the suction machine, and turn the suction on. Wearing sterile gloves, suction a small amount of sterile normal saline from the basin and lightly coat 6 to 8 cm of the catheter with water-soluble lubricant. Using dominant hand, gently but quickly insert the catheter into the patient's nares and intermittently suction and rotate the catheter while withdrawing the catheter. Rinse the catheter and connecting tubing with normal saline and allow the patient to rest 1 to 2 minutes between catheter passes. Encourage the patient to cough, and when suctioning is complete, appropriately discard used equipment and perform oral care.

Apply sterile gloves, pick up the suction catheter with dominant hand, secure the catheter to the tubing, connect the tubing to the suction machine, and turn the suction on

The nurse is performing a dressing change on a patient who is postoperative from a laparotomy. The patient coughs and the nurse sees a few loops of intestine uncoiling from the wound. What is the nurse's best action at this time? Apply sterile gloves and push the intestines back into the wound. Apply sterile saline-soaked towels to the area. Assess the wound to determine the extent of evisceration. Instruct the patient to avoid looking at the wound.

Apply sterile saline-soaked towels to the area

The nurse is preparing to perform nasotracheal suctioning on a patient. Which of the following actions would indicate a break in sterile technique? (Select all that apply.) The nurse applies a sterile glove to the dominant hand and a nonsterile glove to the nondominant hand. As the nurse places the sterile basin on the bedside table, the nurse touches the inside of the basin with the nonsterile glove. The nurse uses the same suction catheter to suction the oral cavity followed by the endotracheal tube and then discards the suction catheter inside the gloves into an appropriate receptacle. The nurse picks up the catheter with the dominant hand, then picks up the connecting tubing with the nondominant hand and secures the catheter to the tubing.

As the nurse places the sterile basin on the bedside table, the nurse touches the inside of the basin with the nonsterile glove The nurse uses the same suction catheter to suction the oral cavity followed by the endotracheal tube and then discards the suction catheter inside the gloves into an appropriate receptacle

The nurse is inserting an indwelling Foley catheter in a male patient. The nurse asks the patient to bear down as if to void and slowly inserts the catheter through the urethral meatus. The nurse advances the catheter and meets resistance. What is the nurse's best initial action at this time? Ask the patient to take slow deep breaths while inserting the catheter slowly. Withdraw the catheter and notify the health care provider. Apply more force to insert the catheter inward. Remove the catheter, apply more lubricant, and reinsert.

Ask the patient to take slow deep breaths while inserting the catheter slowly

Which action can the nurse take to keep a patient from consciously controlling his or her breathing during an assessment? Assess respiration after taking the blood pressure. Assess respiration before measuring the blood pressure. Take the patient's temperature while counting the respiratory rate. Assess respiration after measuring the pulse.

Assess respiration after measuring the pulse

The nurse is preparing to perform oropharyngeal suctioning. Which of the following steps in the sequence is incorrect? Assist the patient into a supine position. Prepare supplies. Turn the suction unit on and set the suction control gauge to high. Connect the suction tubing to the suction machine and to the Yankauer suction catheter. Place the suction catheter in the container of water and apply suction. If the patient has an oxygen device, remove it, placing it near the patient's face. Insert the catheter gently into the mouth along the gingival border (gum line). Gently move the catheter around the patient's mouth until all of the secretions are cleared. Encourage the patient to cough. Replace the oxygen mask. Suction water from the basin through the catheter until the catheter is cleared of secretions. Reassess the patient's respiratory status and repeat the procedure if necessary. Turn off the suction source. Wipe the patient's face. Discard the water into an appropriate receptacle. Discard the Yankauer suction catheter or place it in a nonairtight container to ensure that it remains uncontaminated. Provide oral care. Remove the gloves and perform hand hygiene. Record the procedure.

Assist the patient into a supine position. Prepare supplies. Turn the suction unit on and set the suction control gauge to high. Connect the suction tuning to the suction machine and to the Yankauer suction catheter

Which of the following steps should you take before removing fluid from the balloon in an indwelling urinary catheter? (Select all that apply.) Attach a 2-mL syringe to the balloon port and aspirate the fluid. Correct! Attach a 10 mL or larger syringe to the balloon port and allow the water to passively fill the syringe. Attach a 10- or 20-mL syringe to the balloon port and forcibly aspirate the water. Cut the balloon port and allow the water to slowly drain into a sterile basin. Correct! Gently aspirate the syringe plunger if water remains in the balloon.

Attach a 10ml or larger syringe to the balloon port and allow the water to passively fill the syringe Gently aspirate the syringe plunger if water remains in the balloon

Identify the equipment needed to pouch an enterostomy by using a precut system. (Select all that apply.) Basin with warm tap water. Gauze pads or washcloth. Towel or disposable waterproof barrier. Sterile gloves. Pouch closure device, such as a clamp. Clean disposable gloves. Pouch: clear drainable colostomy/ileostomy in correct size for two-piece system or a one-piece type with attached skin barrier.

Basin with warm tap water Gauze pads or washcloth Towel or disposable waterproof barrier Puch closure device, such as a clamp Clean disposable gloves Pouch: clean drainable colostomy/ileostomy in correct size for two-piece system or a one-piece type with attached skin barrier

A nurse is performing preoperative teaching for a patient who is having urological surgery. The nurse informs the patient he will likely require closed bladder irrigation following the surgery. The patient asks what the purpose is for bladder irrigation. What would be a correct response by the nurse? (Select all that apply.) "Bladder irrigation may be used to instill medication into the bladder." "The irrigating solution helps kill any bacteria that may be present in the bladder." "Irrigating the bladder prevents any clots or sediment from blocking urinary drainage." "Bladder irrigation is one method used to treat pain after urological surgery." "Irrigating the bladder applies pressure to prevent bleeding at the operative site."

Bladder irrigation may be used to instill medication into the bladder Irrigating the bladder prevents any clots or sediment from blocking urinary drainage

How is the vacuum re-established after emptying a drain such as a Jackson-Pratt drain or Hemovac? By turning the suction on. By "milking" the tubing. By compressing the drain reservoir. By keeping the drain lower than the insertion site.

By compressing the drain resevoir

Which of the following is the best example of documentation on a patient with a urinary catheter? Catheter care provided; no encrustation noted. Urinary catheter patent and draining clear yellow urine to bedside drainage bag. Catheter care provided. 14 French catheter intact with approximately 30 mL urine in bedside drainage bag. Unable to palpate urinary bladder. Patent denies discomfort; indwelling catheter draining well. Patient instructed on signs and symptoms of UTI and how to prevent while catheterized.

Catheter care provided; no encrustation noted. Urinary catheter patent and draining clear yellow urine to bedside drainage bag

The nurse may use clean gloves for changing the dressing on which of the following? Surgical wound. Sterile gloves should always be used for dressing changes performed in the hospital setting. Sterile gloves should always be used for dressing changes performed by nurses. Chronic pressure injury.

Chronic pressure injury

A nurse is explaining how to perform a dressing change. Which of the following sequences for changing a surgical wound dressing (wound drain present) indicates that the nurse requires further education regarding this procedure? Use sterile dry gauze to blot dry. Apply prescribed antiseptic ointment by using the same technique as for cleansing. Apply loose, woven gauze as contact layer. Place drain sponge (precut gauze) around drain. Apply additional layers of gauze as needed. Apply thicker woven pad (e.g., ABD or Surgipad). Dispose of gloves and soiled dressings in waterproof bag. Perform hand hygiene. Create a sterile field with individually wrapped sterile supplies on the over-bed table. Pour necessary prescribed solution into sterile basin. Apply sterile gloves. Cleanse wound. Use a separate swab for each cleansing stroke. Clean incision from top to bottom. Cleanse around drain by using a circular stroke starting near the drain and moving outward. Cleanse wound. Use a separate swab for each cleansing stroke. Cleanse around drain by using a circular stroke starting near the drain and moving outward. Clean incision in direction of bottom to top.

Cleanse wound. Use separate swab for each cleansing stroke. Cleanse around drain by using a circular stroke starting near the drain and moving outward. Clean incision in direction of bottom to top

From the following, choose the correct equipment to bring to the bedside to administer the commercially prepared Fleet enema. (Select all that apply.) Commercially prepared enema product. Water-soluble lubricant. You Answered Enema bag. Clean disposable gloves. Waterproof bed pad. Sterile gloves. Tubing with a rectal tip. Toilet paper and/or basin with warm water, washcloth, and towel.

Commercially prepared enema product Water-soluble lubricant Clean disposable gloves Waterproof bed pad Toilet paper and/or basin with warm water, washcloth, and towel

During the assessment of a patient's respiratory rate, when the second hand reaches the 15-second mark, the respiratory count is 8. What should the nurse do at this time? Stop the assessment, and multiply the number 8 by 2. Stop the assessment. Stoop the assessment, and multiply the number 8 by 6. Continue to count the patient's breath for a full 60 seconds.

Continue to count the patient's breath for a full 60 seconds

On the last assessment of a patient's respiration, her respiratory rate was 10 breaths per minute. What should the nurse do when conducting the next assessment of this patient's respiratory rate? Count breaths for 15 seconds and multiply by 4. Count breaths for 30 seconds and multiply by 2. Count breaths for 10 seconds and multiply by 6. Count breaths for 60 seconds.

Count breaths for 60 seconds

Which of the following, if exhibited by the patient, is a late sign of hypoxia? Restlessness. Anxiety. Eupnea. Cyanosis.

Cyanosis

The patient reports an allergy to latex. What alterations should be made in the patient's care? (Select all that apply.) Determine whether syringes, IV tubing, and catheters contain latex. Remove items that contain latex in the care of the patient. Have a nurse who is also allergic to latex provide the patient's care. Avoid wearing gloves unless absolutely necessary and only for short periods. Avoid use of alcohol-based hand rubs. Use latex-free or synthetic gloves when gloves are necessary.

Determine whether syringes, IV tubing, and catheters contain latex Remove items that contain latex in the care of the patient Use latex-free or synthetic gloves when gloves are necessary

A nurse is preparing a medication for subcutaneous administration. As the nurse recaps the needle using the scoop method, the nurse accidentally touches the table with the uncovered needle. What is the nurse's best action? Discard the needle, syringe, and medication and start over. Discard the needle and replace with a new one before administration. Wipe the needle with an alcohol swab and recap for use. Transfer the medication to a new syringe.

Discard the needle and replace with a new one before administration

Which of the following may indicate internal hemorrhage? (Select all that apply.) Distention or swelling of the affected body part. An elevated white blood cell count. A decreased blood pressure and increased pulse. A change in the type and amount of drainage from a surgical drain. Purulent drainage and tenderness at wound site.

Distention or swelling of the affected body part A decreased blood pressure and increased pulse A change in the type and amount of drainage from a surgical drain

Which instruction would the nurse give when asking nursing assistive personnel (NAP) to give a complete bed bath to a patient? Do not massage any reddened areas on the patient's skin. Be sure to wash the patient's face with soap. Wear gloves if necessary. Disconnect the intravenous tubing when changing the gown.

Do not massage any reddened areas on the patient's skin

The nurse is helping a patient get out of a bathtub, and the patient appears to be unsteady on her feet. What should the nurse do to help ensure the patient's safety? Drain the bathtub before the patient gets out. Drape a bath towel over the patient's shoulders. Apply lotion to the patient's freshly dried skin. Demonstrate how to use the call light for assistance.

Drain the bathtub before the patient gets out

When is a surgical wound at greatest risk for hemorrhage? Four to five days after surgery. Two to three days after surgery. During the first 24 to 48 hours after surgery. Five to seven days after surgery.

During the first 24 to 48 hours after surgery

From the following, choose the four primary functions of the colon. (Select all that apply.) Transference. Elimination. Reuptake. Absorption. Protection. Secretion.

Elimination Absorption Protection Secretion

The nurse is teaching a patient how to empty his Hemovac drain. Which action of the patient indicates that further instruction is needed? The patient: opens the plug on the port for emptying the drainage reservoir and drains the contents into the measuring container. presses downward until the bottom and top of the Hemovac are in contact to reestablish the vacuum. holds the surfaces of the Hemovac together with one hand, cleans the opening and plug with an alcohol swab with the other hand, and immediately replaces the plug. empties the Hemovac drain, replaces the plug, and records the amount of drainage.

Empties the Hemovac drain, replaces the plug, records the amount of drainage

What nursing intervention is appropriate for the patient with a large amount of sputum? Perform nasotracheal suctioning every hour. Encourage the patient to cough every hour while awake. Place the patient on fluid restriction. Avoid all milk products.

Encourage the patient to cough every hour while awake

The nurse plans to assess a patient's respiratory rate; however, the patient has just returned from ambulating to the bathroom. What should the nurse do to minimize the effect of exercise on the patient's respiratory rate? Encourage the patient to rest for 10 minutes before assessing respiration. Compare the postexercise respiratory rate with his baseline findings. Compare the postexercise findings with the previous attest findings. Assess the pulse for a full 60 seconds before assessing respiration.

Encourage the patient to rest for 10 minutes before assessing respiration

What should the nurse do when a patient is ordered to receive 4 L/min oxygen by nasal cannula? Ensure that humidification is present. Encourage oral fluids. Restrict fluids. Measure blood pressure every hour.

Ensure that humidification is present

The nursing assistive personnel (NAP) reports the patient who is 1 day postoperative from bladder surgery is complaining of lower abdominal pain. The nurse palpates the patient's bladder and finds it is distended and there has not been any change in the amount of urine in the last 2 hours in the drainage bag. The patient's vital signs are within normal limits. What is the nurse's best action? Encourage the patient to drink more fluids and request an order to increase the patient's rate of intravenous (IV) fluids. Note if the urine is cloudy or has a foul odor, obtain a sterile urine specimen, and request an order for a urinalysis. Provide the patient with pain medication, and inform him this is a normal finding during the early postoperative period. Ensure there are no kinks in drainage tubing, and if none, notify health care provider for possible bladder irrigation order.

Ensure there are no kinks in drainage tubing, and if none notify healthcare provider for possible bladder irrigation order

When caring for a patient who is receiving supplemental oxygen by face tent, which action ensures that the oxygen is flowing? Routinely monitoring the seal over the patient's mouth and nose Ensuring that a mist is always present Regularly verifying that the mask is positioned loosely Testing the closing capacity of the mask's valves

Ensuring that a mist is always present

How often should an ostomy pouch be changed? Every 2 weeks. Every other day. Every 3 to 7 days. Daily.

Every 3 to 7 days

A contaminated or traumatic wound may show signs of infection within 24 hours. A surgical wound infection usually develops postoperatively within 14 days. True False

False

For a patient with an endotracheal tube on mechanical ventilation, preoxygenation is unnecessary before suctioning because the ventilator will maintain the patient's oxygen levels. True False

False

Identify the indicators of a UTI: (Select all that apply.) Fever. Urinary drainage. Complaints of pain with urination (dysuria). Hypothermia. Lower abdominal pain. Cloudiness of the urine.

Fever Complaints of pain with urination (dysuria) Lower abdominal pain Cloudiness of the urine

A patient with lung cancer received radiation therapy to reduce the size of the tumor before a lobectomy (surgical removal of part of the lung). The patient is now being seen on home health services for packing of an abnormal passage between the patient's chest cavity and an opening on the patient's back. The nurse is aware the patient is at increased risk for: Fluid and electrolyte imbalance. Hemorrhage. Edema. Nerve damage with decreased sensation.

Fluid and electrolyte imbalance

The nurse is working in a busy emergency room. On entering station 1, the nurse dons a pair of clean disposable gloves. The nurse sees that the patient has a gunshot wound to the chest and is concerned there may be splattering of infectious materials. The nurse applies goggles, a mask, and a gown. What is this called? Following standard precautions. Using medical asepsis. Using surgical asepsis. Infection control to prevent a health care-acquired infection.

Following Standard Precautions

The NAP tells the nurse she doesn't want to care for a certain patient because she is afraid of contracting C. difficile. Which is the best response by the nurse? "C. difficile can only be acquired through antibiotic therapy, chemotherapy, or invasive bowel procedures." "C. difficile is the organism responsible for duodenal ulcers." "Good hand hygiene with soap and water is your best defense against C. difficile." "I can reassign you to care for a different patient."

Good hand hygiene with soap and water is your best defense against C.difficle

Which personal protective equipment (PPE) will the nurse wear if there is a risk of a blood splash when caring for a patient? Gown Gown, gloves, and mask Gown and gloves Gown, gloves, mask, and eye protection

Gown, gloves, mask, and eye protection

The nurse has washed a patient's arms. Which area should the nurse wash next? Abdomen Legs Hands Chest

Hands

Under which circumstance(s) should hand washing be repeated? (Select all that apply.) Hands touch the sink during hand washing. Areas under fingernails remain soiled. Cracked areas are noted on the nurse's hands. Hands are free of visible soiling. Hands are lowered below waist level.

Hands touch the sink during hand washing Areas under fingernails remain soiled

The nurse is to determine PVR on a patient who has been experiencing incontinence, but a bladder scanner is unavailable. What is the nurse's best action? Have the patient void and measure the amount; have the patient void again and measure the volume within 5 to 15 minutes of the first voiding. Notify the health care provider. Document hourly outputs using a urinometer. Have the patient void and measure the volume, then perform straight catheterization.

Have the patient void and measure the volume, then perform straight catheterization

Which of the following are common sites for the development of pressure injuries? (Select all that apply.) Sternum. Heels. Sacrum. Lateral malleoli. Trochanters. Ischial tuberosities.

Heels Sacrum Lateral malleoli Trochanters Ischial Tuberosities

An elderly patient is admitted for back surgery. She is now retired but her previous occupation was as a registered nurse. She reports that she is also allergic to morphine and penicillin. She has a history of five laminectomies (back surgeries) resulting from scoliosis as a child. She has three children who visit her. She requires a cane to ambulate. Which factors would be considered high-risk factors for latex allergy? (Select all that apply.) Her age. History of multiple surgeries as a child. Allergy to morphine and penicillin. Occupation. Use of a cane.

History of multiple surgeries as a child Occupation

The nurse is applying sterile gloves. Which series of steps would require correction? Perform hand hygiene. Examine glove package to determine if it is dry and intact. Open sterile gloves by carefully separating and peeling open the adhered package edges. Identify right and left glove. With thumb and first two fingers of nondominant hand, grasp edge of the cuff of the glove for the dominant hand. Touch only inside surface of the glove and pull the glove over the dominant hand, carefully working the thumb and fingers into the correct spaces. Gently let go of the cuff while preventing it from rolling up the wrist. Slide the fingers of the gloved hand underneath the second glove's cuff. Pull the glove over the fingers of the nondominant hand. Avoid touching exposed areas with the gloved hands. Correct! Hold gloved hands at sides of body, below waist level, until beginning the sterile procedure.

Hold gloved hands at sides of body, below waist level, until beginning the sterile procedure

The nurse has prepared a sterile field and added the necessary sterile items to the field. The nurse has applied sterile gloves and is waiting to assist the health care provider in performing a surgical procedure. The nurse keeps the sterile field in view and holds her hands down at her side, away from her clothing. While waiting, the nurse instructs the patient to avoid touching the sterile field and for the need to lie still. Which action made by the nurse is incorrect? Failing to cover up the sterile field with a sterile drape while waiting. Holding gloved hands at her side. The patient teaching. All actions are appropriate.

Holding gloved hands at her side

A nurse reads the following documentation in a patient's electronic health record: 92-year-old female complains of frequent nonproductive cough. States has been taking PO steroids as prescribed. Denies having received pneumonia vaccine. B. Jones, R.N. Based on this information, what factors place this patient at risk for being a susceptible host? (Select all that apply.) Hospitalized. Nutritional status. Age. Gender. Vaccination status. Medical therapy.

Hospitalized Age Vaccination Status Medical therapy

The nurse is discussing the guidelines for proper use of PPE by nursing assistive personnel (NAP). Which statement made by the NAP requires follow-up by the nurse? I always do hand hygiene when entering and leaving a patient's room. When in doubt, I wear gloves. I wear a mask whenever I am caring for a patient who's coughing. I really dislike wearing a mask, so it's the first thing I take off.

I really dislike wearing a mask, so it's the first thing I take off

The nurse is teaching the patient how to pouch an ostomy. Which statement, if made by the patient, indicates further instruction is needed? "As long as it isn't leaking, the skin barrier can remain in place for a week." "I should clean the peristomal skin with soap and warm water." "If I touch the stoma during cleaning, minor bleeding is normal." "Adhesive remover aids in removal of the skin barrier."

I should clean the peristomal skin with soap and warm water

The nurse is reviewing how to perform a bladder scan for determining postvoid residual (PVR) with nursing assistive personnel (NAP). Which of the following statements, if made by the NAP, indicates understanding? (Select all that apply.) "This test requires the patient to follow fluid intake restrictions." "I will measure and record the patient's intake and output." "I will perform the bladder scan and then have the patient urinate." "I will apply ultrasound gel above the patient's symphysis pubis." "I should point the scanner head downward toward the bladder."

I will measure and record the patient's intake and output I will apply ultrasound gel above the patient's symphysis pubis I should point the scanner head downward toward the bladder

Which statement by the patient would indicate that he or she understands the safe use of oxygen? The nurse told me that my oxygen saturation must be maintained at 85% or above. I know that oxygen is a medication I an adjust whenever I need to I often experience difficulty breathing for no apparent reason, but that is expected. I'll alert the nurse immediately if I have any increased difficulty breathing.

I'll alert the nurse immediately if I have any increased difficulty breathing

The nurse has delegated administration of a standard enema for a 72-year-old patient with constipation. Which statement made by nursing assistive personnel (NAP) requires the nurse to follow-up? I'll place the patient in the left side-lying position with the right knee bent. I'll put a waterproof pad under the patient before I start. I'll warm up the solution before instilling it. I'll instill the solution and then check in on my other patients until I get the call signal.

I'll instill the solution and then check in on my other patients until I get the call signal

The nurse is reviewing with the surgical technician how to prepare a sterile field. Which of the following should be included in the discussion? (Select all that apply.) If there is any question or doubt of an item's sterility, the item is considered to be nonsterile. When using a sterile drape, position the bottom half of the sterile drape over the top of the intended sterile field. When using a sterile barrier, touch only the outer 2 inches (5 cm) of the border because this is considered nonsterile. When pouring a solution, if some spills onto the sterile barrier, cover the spill with sterile gauze. When preparing a sterile field, unwrap the commercial tray by beginning with the outermost flap and unfolding it in the direction away from the sterile kit toward the top of what will be the sterile field.

If there is any question or doubt of an item's sterility, the item is considered to be nonsterile When using a sterile drape, position the bottom half of the sterile drape over the top of the intended sterile field When preparing a sterile field, unwrap the commercial tray by beginning with the outermost flap and unfolding it in the direction away from the sterile kit toward the top of what will be the sterile field

The nurse is preparing an in-service on medical asepsis. Which of the following should be included in the presentation? (Select all that apply.) Use sterile gloves if anticipating contact with nonintact skin. Artificial nails should be no longer than 0.625 cm (1/4 inch). If worn, fingernail polish should not be chipped. Cough hygiene practices should be followed. Gown and gloves are sufficient PPE for a splash risk. Always know a patient's susceptibility to infection.

If worn, fingernail polish should not be chipped Cough hygiene practices should be followed Always know a patient's susceptibility to infection

A nurse is teaching infection control to a group of daycare workers. Which of the following should the nurse include in the instruction? Washing hands with soap and water is the only effective means for stopping the spread of germs. Immunizations help protect children from being susceptible hosts. Large containers of hand sanitizer should be made available for use when there is visible soiling. Toys are typically the reservoir of pathogen growth.

Immunizations help protect children from being susceptible hosts

The comatose patient in the intensive care unit (ICU), who has not had a bowel movement in 4 days, suddenly is incontinent of liquid stool. What should the nurse suspect? Diarrhea as a result of decreased muscle tone. Impaction. The patient had a vagal response. Flatulence.

Impaction

Which of the following would be inappropriate to delegate to NAP? Application of a condom catheter. Perineal care. Emptying a leg bag and recording on I&O record. Indwelling catheter insertion.

Indwelling catheter insertion

Which of the following requires strict surgical asepsis? Emptying a bedside drainage bag Insertion of an indwelling catheter Applying a condom catheter Performing catheter care

Insertion of an indwelling catheter

When preparing the patient's environment for safe oxygen therapy, which intervention is a priority to minimize the patient's risk for injury? Instruct nursing assistive personnel (NAP) to immediately correct or report safety hazards. Place appropriate signage to alert staff and visitors to the presence of oxygen in the patient's room. Inspect all electrical equipment in the patient's room for the presence of safety-check tags. Ensure that the patient receives the prescribed amount of oxygen via the appropriate method.

Inspect all electrical equipment in the patient's room for the presence of safety-check tags

After determining the proper size stocking and assessing the patient's circulatory status, a nurse delegates the application of elastic stockings to nursing assistive personnel (NAP). The nurse discovers that the NAP has been using moisturizer on the patient's legs before applying the stockings. What is the best action by the nurse? Explain that moisturizer may cause excessive skin softening, which can lead to skin breakdown. Inspect the patient's skin for color variations. Instruct NAP to use a small amount of cornstarch or powder. Ask the patient if he or she is allergic to the moisturizer.

Instruct NAP to use a small amount of cornstarch or powder

The nurse reports that a patient has a wound on his abdomen that is healing by secondary intention. The nurse understands this means the patient: has a drain. Is at greater risk for infection. Is at greater risk for wound dehiscence. Is healing naturally.

Is at greater risk for infection

Identify the functions of dressings. (Select all that apply.) Maintaining a moist environment. Removing surface bacteria. Control of bleeding and drainage. Increased patient comfort. Protection from outside contaminants and further tissue injury. Preventing shear.

Maintaining a moist environment Control of bleeding and drainage Increased patient comfort Protection from outside contaminants and further tissue injury

A nurse is explaining the procedure for inserting an indwelling urinary catheter. Which of the following explanations regarding anchoring of the catheter would be most accurate? An indwelling catheter tube is secured to a female patient's abdomen to prevent accidental dislodgment. An indwelling catheter tube is secured to the male patient's inner thigh with a strip of nonallergenic tape or a commercial tube holder. It is important to anchor the catheter tubing to minimize the risk for urethral trauma and bladder spasms from traction and to prevent accidental dislodgment. When securing the catheter tubing, slack in the catheter should be avoided to prevent movement and possible tissue injury.

It is important to ancho the catheter tubing to minimize the risk for urethral trauma and bladder spasms from traction and to prevent accidental dislodgment

The nurse is teaching the male patient and family caregiver about the advantages of a condom catheter. Which of the following should be included in the teaching? (Select all that apply.) It is relatively safe and noninvasive. It ensures complete bladder emptying. It is a convenient method of draining urine. It is used for male patients who are incontinent. It may remain in place for several weeks at a time. It carries less risk of developing a UTI than an indwelling catheter.

It is relatively safe and noninvasive It is a convenient method of draining urine It is used for male patients who are incontinent It carries less risk of developing a UTI than an indwelling catheter

The nurse is delegating to nursing assistive personnel (NAP) the administration of an enema for an older adult patient who is recovering from a stroke. The enema order reads, Enemas until clear. Which statement made by NAP requires the nurse to follow-up? I'll test the water temperature on the inside of my own wrist. I'll need help to turn her onto her side. It may take three or four enemas to achieve a clear return. The enema will wear her out, so I'll wait until after she ambulates.

It may take three or four enemas to achieve a clear return

A patient has been admitted for surgery for a colostomy. The patient states, "I can't believe this has happened to me." What is the nurse's best response? "It will be a change for you, but a normal lifestyle is still possible. What concerns you the most?" "You sound like you are in disbelief. Why do you feel this way?" "Don't worry, many patients have had this same surgery and learn to manage very well." "How has your husband reacted to the news?"

It will be a change for you, but normal lifestyle is still possible

Which of the following actions associated with urinary catheterization could cause a potential problem? Attaching the bedside drainage bag to the bed frame. Keeping the foreskin retracted after catheterization. Failing to test the balloon by injecting fluid from prefilled sterile water syringe into the balloon port before insertion. Cleansing the far labial fold, the near labial fold, and directly over the center of urethral meatus using a new swab with each area.

Keeping the foreskin retracted after catheterization

The nurse has inserted a catheter 7.5 cm (3 inches) in a female patient and obtains no urine return even though her bladder is distended. What action should the nurse take at this time? Remove the catheter and have another nurse attempt to catheterize the patient. Leave the catheter in the vagina as a landmark and insert another sterile catheter. Remove the catheter and reinsert into the urethra. The nurse may straighten the urethra by inserting one finger of a sterile-gloved hand inside the vagina and applying gentle pressure upward. Inflate the balloon and reassess in 1 hour for urine return in the bedside drainage bag.

Leave the catheter in the vagina as a landmark and insert another sterile catheter

What can the nurse do to keep the patient from becoming chilled while receiving a bath with a disposable bath-in-a-bag product? Dry each body part with a warmed towel after washing. Keep the patient's gown on for the bath. Lightly cover the patient with a bath towel. Wash the product off of the skin with a warm, moistened washcloth.

Lightly cover the patient with a bath towel

What would the nurse monitor frequently to ensure that the prescribed amount of oxygen is being delivered to a patient? Arterial blood gas (ABG) levels Temperature Respiratory rate Oxygen flow meter setting

Oxygen flow meter setting

The nurse is observing the patient's wife perform the damp-to-dry dressing change. Which actions, if made by the patient's wife, indicate that further instruction is needed? (Select all that apply.) Premedicates for pain. Packs wound tightly. Leaves contact or primary dressing dripping moist. When removing the old dressing the wife leaves the dressing dry, even when it sticks slightly. Pulls tape in direction toward wound when removing previous dressing.

Packs wound tightly Leaves contact or primary dressing dripping moist

When preparing to clean a patient's dentures using the sink, the nurse first protects the dentures by doing what? Filling the sink with hot water Performing hand hygiene Padding the sink basin with a washcloth Filling the sink with cold water

Padding the sink basin with a washcloth

Which action would the nurse take to reduce the risk of infection among patients and staff when administering an enema to an older adult patient with dementia? Which action would the nurse take to reduce the risk of infection among patients and staff when administering an enema to an older adult patient with dementia? Lubricate the tip of the rectal tube. Pad the patient's bed thoroughly. Help the patient onto a bedpan to expel the enema fluid and stool. Correct! Perform hand hygiene before donning gloves.

Perform hand hygiene before donning gloves

What is the best nursing practice to reduce the potential transmission of microorganisms within the health care setting? Bagging all linen. Performing hand hygiene. Keeping catheter bags empty. Wearing gloves.

Performing Hand Hygiene

The nurse is preparing continuous bladder irrigation. Which of the following actions by the nurse would be appropriate? (Select all that apply.) Performing hand hygiene and donning clean gloves. Priming the infusion tubing with irrigating solution. Clamping the drainage tubing below the injection port. Calculating urinary output as the amount of irrigant infused subtracted from the amount in the drainage bag. Monitoring and emptying the drainage bag as needed.

Performing hand hygiene and donning clean gloves Priming the infusion tubing with irrigation solution Calculating urinary output as the amount of irrigant infused subtracted from the amount in the drainage bag Monitoring and emptying the drainage bag as needed

The nurse is performing routine assessments of the patients on the unit. The nurse notes audible gurgling on inspiration and expiration of the stable postoperative patient. Which of the following tasks can be delegated to competent NAP? Performing oral suctioning. Assessing the adequacy of respiratory functioning. Evaluating the outcome of oral suctioning. Performing nasotracheal suctioning.

Performing oral suctioning

When a patient is receiving oxygen at home, which instruction to the family would help them understand how to use the oxygen safely? Increase the oxygen level as needed for the patient's comfort. Keep oxygen 5 feet (about 1.5 meters) away from anything that could generate a spark. Store extra oxygen cylinders horizontally. Place a No Smoking sign at the entrance to the house.

Place a No Smoking sign at the entrance to the house

Which nursing action reduces the risk of falling as a patient is getting into or out of a bathtub? Add 1 oz of bath oil to the tub water before the patient gets into the tub. Fill the tub half full of water at 110oF to 115oF. Place an "Occupied" sign on the bathroom door. Place a skidproof disposable bath mat in front of the tub.

Place a skidproof disposable bath mat in front of the tub

The nurse is reviewing with the surgical technician how to prepare a sterile field. Which of the following is incorrect and should not be included in the review? Keep your intended work surface above waist level. Place the drape so the top half of the drape is over the top half of the work surface. You may grasp the outer 1-inch border of the drape without wearing sterile gloves. Place sterile items onto the sterile field at an angle.

Place the drape so the top half of the drape is over the top half of the work surface

Before performing endotracheal suctioning, the nurse presses the sigh mechanism on the mechanical ventilator. Why does the nurse do this? The nurse is: (Select all that apply.) preoxygenating the patient. offsetting the volume of oxygen lost during the suction procedure. compensating for the interruption in mechanical ventilation. preventing the development of atelectasis.

Preoxygenating the patient offsetting the volume of oxygen lost during the suction procedure compensating for the interruption in mechanical ventilation

Which action would the nurse take to ensure the safety of an older adult patient who has received an enema? Provide assistance to the bathroom for expulsion of fluid and stool. Instruct the patient to attempt to retain the fluid for 2 to 5 minutes. Assess for the presence of external hemorrhoids. Document the patient's physical response to the enema.

Provide assistance to the bathroom for expulsion of fluid and stool

Which of the following is a correct sequence for changing a gauze dressing? Remove old dressing, discard gloves and perform hand hygiene, create sterile field, apply sterile gloves, clean wound, blot dry, apply new dressing. Remove old dressing, discard gloves, apply new gloves, and apply new dressing. Remove old dressing, discard gloves, clean wound, apply loose woven gauze, and cover with thicker woven pad (e.g., ABD pad). Create sterile field, remove old dressing, discard gloves and perform hand hygiene, apply new gloves, clean wound, blot dry, apply new dressing.

Remove old dressing, discard gloves and perform hand hygiene, create sterile field, apply sterile gloves, clean wound, blot dry, apply new dressing

You are reviewing the signs, symptoms, and prevention of hypoxia with the family of a patient who requires frequent suctioning at home. Choose the information that you should cover. (Select all that apply.) Restlessness and anxiety are indications of hypoxia. Confusion, disorientation, and altered consciousness are indications of hypoxia. Increases in pulse, respiration, and blood pressure are indications of hypoxia. Having difficulty breathing and looking blue are indications of hypoxia. Infection and fever are indications of hypoxia. Bronchitis and chronic obstructive pulmonary disease are indications of hypoxia.

Restlessness and anxiety are indications of hypoxia Confusion, disorientation, and altered consciousness are indications of hypoxia Increases in pulse, respiration, and blood pressure are indications of hypoxia Having difficulty breathing and looking blue are indication of hypoxia

What would the nurse do first when preparing to begin oxygen therapy for a patient? Educate the NAP about the oxygen orders. Review the medical prescription for delivery method and flow rate. Place a No Smoking sign outside of the hospital room. Ensure that suction equipment is present in the room.

Review the medical prescription for delivery method and flow rate

When delegating patient care that requires nursing assistive personnel (NAP) to use personal protective equipment (PPE), it is necessary for the nurse to do what first? Review the patient's need for a specific isolation precaution Discuss what equipment and supplies to bring to the patient's room Document that the care was delegated to the NAP Observe the NAP donning the appropriate PPE

Review the patient's need for a specific isolation precaution

When is the best time to change the skin barrier pouch? (Select all that apply.) After breakfast. After lunch. After dinner. Several hours after breakfast. Several hours after lunch.

Several hours after breakfast Several hours after lunch

The nurse is observing the patient's wife perform treatment of her husband's pressure injury. Which action, if made by the patient's wife, indicates that further instruction is needed? She premedicates the patient for pain before beginning the dressing change. She performs hand hygiene and removes the old dressing and begins to clean the injury with soap and water. While wearing gloves, she rinses the injury with normal saline, gently wiping around the wound base and surrounding skin with moistened gauze. She applies solution to the gauze and wrings out any excess. She unfolds the gauze and packs the wound with the moistened dressing. She covers the gently packed wound with dry 4 × 4-inch gauze pads and applies tape to secure the dressing. She removes her gloves and performs hand hygiene.

She performs hand hygiene and removes the old dressing and begins to clean the injury with soap and water

The nurse is preparing a sterile field. Which of the following would be considered contamination of the field? (Select all that apply.) Correct! Some of the sterile normal saline spills onto the sterile barrier. Correct! Nonsterile items are added to the sterile field. Correct! The nurse prepares the sterile field and leaves the room to get more sterile supplies. The nurse prepares the sterile field immediately before the procedure. When a sterile item falls off the sterile field, the nurse opens a new sterile item.

Some of the sterile normal saline spills onto the sterile barrier Nonsterile items are added to the sterile field The nurse prepares the sterile field and leaves the room to get more sterile supplies

The NAP documents "Peri-care given" next to "Urinary Catheter" on a patient with an indwelling urinary catheter. What is the best explanation of what the NAP did after application of clean gloves? The NAP: washed the perineal area with soap and water and applied a topical antimicrobial ointment at the urethral meatus around the catheter. stabilized the catheter and washed the catheter with soap and water from where the catheter enters the meatus down 4 inches toward the drainage tubing. inserted the hub of syringe into balloon port allowing the sterile water to return passively into the syringe and slid the catheter out into a waterproof pad. obtained a squirt bottle of warm water and had the patient squirt it over their perineum while sitting on the toilet.

Stabilized the catheter and washed the catheter with soap and water from where the catheter enters the meatus down 4 inches toward the drainage tubing

A family member calls the nurse to ask for advice regarding their mother who has developed a "bedsore" on her right heel. The family member describes the pressure injury as "a blister that has now popped and you can see redness." Based on this description, at what stage would the nurse classify this pressure injury? Stage 1. Stage 2. Stage 3. Stage 4.

Stage 2

The nurse manager is reviewing the use of standard precautions with the staff. Which of the following should be included in the review? (Select all that apply.) Standard precautions are used to protect you from potential contact with blood and body fluids. Standard precautions should be observed in every patient encounter. Standard precautions refer only to the use of gloves, not to the use of masks, eye protection, or gowns; these refer to other types of precautions. To follow standard precautions, you must wear sterile gloves. Standard precautions are used once the type of infection is identified.

Standard precautions are used to protect you from potential contact with blood and body fluids Standard precautions should be observed in every patient encounter

The nurse has a sterile urinary catheter and sterile gloves. Choose the remaining equipment the nurse will need to insert a straight urethral catheter: (Select all that apply.) Sterile cotton balls. Antiseptic solution. Sterile urinary collection bag. Water-soluble lubricant. Sterile forceps.

Sterile cotton balls Antiseptic solution Water-soluble lubricant Sterile forceps

Which of the following statements regarding nasotracheal suctioning are true? (Select all that apply.) This procedure can be delegated to NAP. Sterile technique is required. Suction should be applied intermittently as the catheter is removed. The suction catheter should be rotated as it is withdrawn. Clean technique may be used.

Sterile technique is required Suction should be applied intermittently as the catheter is removed The suction catheter should be rotated as it is withdrawn

What must the nurse avoid when brushing the tongue of an unconscious patient? Stimulating the gag reflex Using suction Dislodging bacteria Moistening the oral mucosa

Stimulating the gag reflex

The nurse is preparing to insert a urinary catheter. To perform this procedure, the nurse will use: Surgical asepsis (sterile technique). Medical asepsis (clean technique). Droplet precautions. Standard precautions.

Surgical asepsis (sterile technique)

A patient with a wound vacuum-assisted closure (wound V.A.C.) continues to complain of pain. What measures may be taken? (Select all that apply.) Switch to the white polyvinyl alcohol (PVA) soft foam. Decrease the pressure setting. Administer pain medication. Switch to the black polyurethane (PU) foam. Keep the suction in the "off" position.

Switch to the white polyvinyl alcohol (PVA) soft foam Decrease the pressure setting Administer pain medication

The nurse is observing the NAP perform hand hygiene. Which of the following, if performed by the NAP, requires intervention by the nurse? (Select all that apply.) The NAP: Washes her hands before and after removing clean gloves. Applies 3 to 5 mL of antimicrobial soap to hands wet with warm water. Takes the patient's blood pressure and leaves the room to document. Washes hands with plain soap and water when visibly dirty. Puts the patient's socks on, then begins to feed the patient. Moves the patient's IV pole by the bed and uses hand sanitizer. Has an uncovered cut on the back of the nondominant hand.

Takes the patient's blood pressure and leaves the room to document Puts the patient's socks on, then begins to feed the patient Has an uncovered cut on the back of the nondominant hand

One evaluation measure of creating and maintaining a sterile field involves monitoring the patient for developing signs and symptoms of localized or systemic infection. Which of the following is cause for concern? Correct! Temperature of 102.5° F (39.2° C). Incisional area light pink in color. White blood cell count at 6500 per mm3. Absence of purulent drainage.

Temperature of 102.5F (39.2C)

The nurse is observing the NAP administer a soap suds enema to an adult patient. Which of the following actions, if made by the NAP, would require correction? The NAP holds the enema container approximately 12 inches above the level of the patient's anus. The NAP places the patient in a left side-lying position with the right knee flexed. The NAP inserts the tip of the rectal tube 5 to 7 inches after lubricating it. After filling the enema bag with warmed solution, the NAP raises the container, releases the clamp, and allows the solution to flow to fill the tubing.

The NAP inserts the tip of the rectal tube 5 to 7 inches after lubricating it

The nurse is observing the NAP perform hand washing. During which step should the nurse intervene and provide further instruction? The NAP pushes his wristwatch and long uniform sleeves above the wrists. Standing in front of the sink, the NAP keeps his hands and uniform away from the sink surface. The NAP turns on the water and regulates the flow of water so that the temperature is warm and the force of the spray will not cause splashing. The nurse rinses the hands and wrists thoroughly, dries the hands, and uses a dry paper towel to turn off the hand faucet. Correct! The NAP wets his hands and wrists thoroughly under the running water and keeps his hands and forearms higher than the elbows during washing.

The NAP wets his hand and wrists thoroughly under the running water and keeps his hands and forearms higher than the elbows during washing

A student nurse is studying the GI system in preparation for an exam. Which statement indicates correct understanding? Most absorption of water occurs in the small intestine. The ascending colon would be found in the right side of the patient s abdomen. A patient s heart rate may increase with rectal manipulation, such as removing an impaction. The use of opioids for pain relief and antibiotic therapy places a person at risk for developing diarrhea.

The ascending colon would be found in the right side of the patient's abdomen

The nurse is reviewing urinary catheter care with a newly hired nursing assistive personnel (NAP). Which statement made by the NAP indicates further instruction is needed? "Urinary catheter care is a clean procedure; sterile gloves are unnecessary." "The bedside drainage bag should only be emptied when it is full." "The securement device that anchors the catheter should be reapplied." "Catheter care can be delegated to nursing assistive personnel."

The bedside drainage bag should only be emptied when it is full

Reasons for lack of urine after inserting a straight catheter include: (Select all that apply.) The catheter is outside of the bladder. The catheter is inserted in the vagina rather than in the urethra of a female patient. The male patient's prostate is preventing urine from exiting the bladder. Urethral spasms are preventing urine from exiting the body. The patient's bladder is distended.

The catheter is outside of the bladder The catheter is inserted in the vagina rather than in the urethra of a female patient

A patient has a loop colostomy. The patient complains that the distal stoma looks like it is secreting mucus. What is your best response? "The distal stoma may secrete mucus and that would be normal." "The distal stoma of a loop colostomy is the functional end that excretes urine and requires more frequent changing of the pouch." "The proximal stoma secretes mucus but otherwise is considered nonfunctional. The output from the distal stoma is called effluent." "Let me take a look at your pouch of the distal stoma; perhaps it is leaking."

The distal stoma may secrete mucus and that would be normal

You are washing your hands in a sink with hand faucets. You first turn on the water and regulate the temperature to warm. You increase the water pressure to create a strong spray. You wet your hands, apply 1 teaspoon (5 mL) of soap, and rub your hands together vigorously, creating lather. You interlace your fingers and rub the palms and backs of the hands with a circular motion at least 5 times each. You keep your hands positioned with fingertips down and rinse the hands and wrists thoroughly. You turn off the faucet. You dry your hands with a paper towel. Which step(s) are incorrect? (Select all that apply.) The temperature of the water. The force of the water. The amount of soap used. The technique used in lathering. The position of your hands. The method used to turn off the faucet.

The force of the water The method used to turn off the faucet

During change-of-shift report the nurse states that a patient has early renal failure and to be alert to this when administering medications. Why would this be a concern? The kidneys assist in the detoxification of medication metabolites. The patient may not be able to absorb all of the medications. The bladder acts as a filter to remove wastes and form urine. The kidneys are the primary site for medication metabolism.

The kidneys assist in the detoxification of medication metabolites

A nurse is to perform a bladder scan on a patient to measure PVR. After the patient voids, the nurse measures and documents the volume of voided urine. The nurse returns in 20 minutes and places the patient supine with head slightly elevated, exposing the patient's lower abdomen. The nurse turns on the scanner and sets the gender designation. The nurse applies a generous amount of ultrasound gel above the patient's symphysis pubis, and releases the scan button and then applies the scanner head to the gel, pointing it in a downward direction toward the bladder. The nurse wipes the abdomen of the gel and documents the procedure. What error(s) occurred in the performance of the skill? (Select all that apply.) The order of having the patient void followed by the bladder scan. The positioning of the patient. The length of time between the patient voiding and performing the bladder scan. The timing of pressing and releasing the scan button. The amount of ultrasound gel applied. Cleaning of the scanner head.

The length of time between the patient voiding and performing the bladder scan The timing of pressing and releasing the scan button Cleaning of the scanner head

When measuring a patient's respiratory rate, the nurse will count the number of completed respiratory cycles per minute. What is the definition of a respiratory cycle? The number of sighs per minute. The number of expirations per minute. The number of inspirations per minute. The number of inspirations and expirations per minute.

The number of inspirations and expirations per minute

The nurse changes the dressing of your first patient with methicillin-resistant Staphylococcus aureus of the wound. The nurse discards the gloves and goes into the next room, where the nurse suctions a second patient s airway. According to the chain of infection, the mode of transmission is: Methicillin-resistant Staphylococcus aureus. The first patient. The nurse. The first patient's wound. The second patient. The second patient's respiratory tract.

The nurse

The nurse is preparing to set up a sterile field for a patient who is going to have a sterile dressing change. Which of the following assessment measures would be unnecessary at this time? The nurse reviews documentation to see what supplies will be needed. The nurse asks the patient to rate his pain on a pain scale. The nurse asks the patient if he needs to use the bathroom. The nurse asks the patient if he has ambulated in the hall today.

The nurse asks the patient if he has ambulated in the hall today

Under what circumstances would the nurse assume responsibility for providing denture care for a patient? The patient's previous set of dentures was misplaced or thrown away. Assessment of the oral cavity shows mucositis due to chemotherapy. The dentures belong to the hospital or other facility, rather than to the patient. The patient is unable to care for the dentures on his or her own.

The patient is unable to care for the dentures on his or her own

How can the nurse determine that negative pressure is being achieved with a wound V.A.C.? The nurse can inquire about the patient's pain level. If there is a reported decrease in the level of pain, then the wound is constricting and negative pressure is being achieved. The nurse can ensure that there is no whistling noise at the wound site and that the wound V.A.C. has not triggered its alarm. The nurse can check for air leaks by listening with a stethoscope or by moving the hand around the edges of the wound while applying light pressure. The nurse can ensure that the foam is in contact with the entire wound base, margins, and tunneled and undermined areas.

The nurse can check for air leaks by listening with a stethoscope or by moving the hand around the edges of the wound while applying light pressure

The nurse is pouching an enterostomy. Assuming all other steps are performed correctly, which of the following steps is incorrect? The nurse observes the skin barrier for leakage and length of time in place. The nurse cleans the peristomal skin vigorously with warm tap water, selects a pouch, removes the backing and cuts the opening on the pouch to one-quarter inch larger than the stoma. The nurse applies the pouch over the stoma pressing firmly around stoma and outside edges, and has the patient hold hand over pouch to apply heat to secure seal. The nurse removes drape from patient, removes gloves, and performs hand hygiene. The nurse documents the procedure.

The nurse cleans the peristomal skin vigorously with warm tap water, selects a pouch, removes the backing and cuts the opening on the pouch to one-quarter inch larger than the stoma

A nurse is applying negative-pressure wound therapy (e.g., wound vacuum-assisted closure [V.A.C.]) independently for the first time. Assuming all other steps are performed correctly, which action, if made by the nurse, indicates that further instruction is needed in performing this procedure? The nurse applies the tubing to the foam in the wound, applies a skin protectant to skin around the wound, and applies the transparent dressing, covering 3 to 5 cm (1.2 to 2 inches) of surrounding healthy tissue. With the V.A.C. unit off, the nurse applies clean gloves and disconnects the tubes to drain fluids into the canister. The nurse cuts the foam approximately one-half inch smaller than the size of the wound and gently places the foam in the wound, avoiding any tunneled and undermined areas. With dressing tube unclamped, the nurse instills 10 to 30 mL of normal saline into the tubing to soak the foam underneath.

The nurse cuts the foam approximately one-half inch smaller than the size of the wound and gently places the foam in the wound, avoiding any tunneled and undermined areas

A patient with a double-lumen urinary catheter has an order for closed intermittent catheter irrigation. The nurse performs hand hygiene, applies clean gloves, draws up 50 mL of room temperature irrigating solution into a sterile syringe, and places a sterile cap on the end. The nurse wipes the catheter and drainage tubing junction with an alcohol swab, disconnects the catheter from the drainage tube, inserts the needleless syringe, and gently instills the irrigating solution at an even, steady rate. The nurse reconnects the drainage tubing and observes the fluid return for color and any sediment or clots. What aspect of skill performance, if any, was in error? The nurse should have worn sterile gloves. The temperature of the irrigating solution was incorrect. The nurse disconnected the drainage tubing from the catheter. The rate at which the irrigating solution was instilled was incorrect. The nurse performed closed intermittent catheter irrigation correctly.

The nurse disconnected the drainage tubing from the catheter

A nurse is preparing to administer an enema. Which of the following actions indicates correct understanding? nurse holds the tubing in the patient's rectum constantly until the end of fluid instillation. The nurse administers a normal saline enema without a health care provider's order when the patient hasn't had a bowel movement after 3 days. The nurse places the male patient in the dorsal recumbent position for enema administration. The nurse adds 5 mL of castile soap to the enema bag and then fills it to the prescribed level with warm water.

The nurse holds the tubing in the patient's rectum constantly until the end of fluid instillation

A nursing student is watching a nurse catheterize a female patient with an indwelling catheter. Which of the following, if it occurs, indicates a break in sterile technique? (Select all that apply.) The nurse inserts the urinary catheter, and when urine does not return, removes the catheter and makes a second attempt to locate the urethra with the same catheter. The nurse lubricates the catheter and places it back into the sterile tray when it uncoils and touches the bed. After the nurse cleans the labia, the labia become slippery and closed as the nurse attempts to obtain a clear view of the urethra. The nurse advances the catheter another 2.5 to 5 cm (1 to 2 inches) after urine appears, releases the labia, and holds on to the catheter with the nondominant hand. The nurse uses forceps and a new cotton ball when cleansing the area, wiping along the far labial fold, the near labial fold, and directly over the center of the urethral meatus.

The nurse inserts the urinary catheter, and when urine does not return, removes the catheter and makes a second attempt to late the urethra with the same catheter The nurse lubricates the catheter and places it bac into the sterile tray when it uncoils and touches the bed After the nurse cleans the labia, the labia becomes slippery and closed as the nurse attempts to obtain a clear view of the urethra

The nurse is caring for a patient with a Jackson-Pratt drain. Which of the following indicates correct understanding? (Select all that apply.) The nurse pins the Jackson-Pratt drain above the wound. The nurse instructs the NAP to measure the drainage and record on the intake & output form every 8 to 12 hours and as needed for large drainage volume. The nurse expects the Jackson-Pratt drain to be used when there is a large amount of drainage (500 mL). The nurse ensures the drainage device appears deflated after it is emptied. The nurse instructs the NAP to determine and report what type of drainage is present in the Jackson-Pratt drain.

The nurse instructs the NAP to measure the drainage and record on the intake and output form every 8 to 12 hours as needed for large drainage volume The nurse ensures the drainage device appears deflated after it is emptied

The nurse is catheterizing a male patient. Which of the following demonstrates correct understanding of the procedure? (Select all that apply.) The patient is placed in a dorsal recumbent position for urinary catheter insertion. The patient is placed in a supine position with legs slightly abducted. The nurse applies sterile gloves before opening the antiseptic solution and lubricant. The nurse cleans the urethral meatus using a circular motion beginning at the meatus and working outward in a spiral pattern.

The patient is placed in a supine position with legs slightly abducted The nurse applies sterile gloves before opening the antiseptic solution and lubricant The nurse cleans the urethral meatus using a circular motion beginning at the meatus and working outward in a spiral pattern

The nursing instructor is reviewing the renal system and urinary catheterization with her students. Which statement, if made by a nursing student, indicates that further instruction is needed? "The urinary tract is considered to be sterile." "The nurse may use clean technique to insert an indwelling catheter." "The urge to void is felt when the bladder contains 150 to 200 mL in an adult." "The minimum average hourly urine output is 30 mL."

The nurse may use clean technique to insert an indwelling catheter

The nurse is adding a dry sterile gauze dressing to the sterile field. The dressing bounces on the surface and lands on the outer 1-inch border of the sterile field. What action is appropriate at this time? The nurse discards the entire sterile field, all items on it, and starts over. The nurse opens another sterile gauze dressing and adds it to the sterile field, but does not use the first one. Once sterile gloves are applied, the nurse moves the sterile gauze dressing to the center of the sterile field. The nurse continues with the procedure adding supplies to the sterile field and using each of them as needed.

The nurse opens another sterile gauze dressing and adds it to the sterile field, but does not use the first one

The nurse is caring for a patient after major abdominal surgery. Which of the following demonstrates correct understanding of wound dehiscence? Correct! The nurse should be alert for an increase in serosanguineous drainage from the wound. Wound dehiscence is most likely to occur during the first 24 to 48 hours after surgery. The nurse should administer cough suppressant to prevent wound dehiscence. The condition is an emergency that requires surgical repair.

The nurse should be alert for an increase in serosanguineous drainage from the wound

The health care provider has ordered a Fleet enema for a patient experiencing constipation. Which of the following actions would require correction? The nurse delegates the task to nursing assistive personnel (NAP). The nurse removes the protective cap from the rectal tip. The nurse squeezes and releases the bottle several times until all of the solution has entered the patient. The nurse administers the enema at room temperature, or if too cool, warms the solution by holding the bottle under warm running water.

The nurse squeezes and releases the bottle several times until all of the solution has entered the patient

The nurse understands the important role in helping the patient with an ostomy accept their change in self-image. Which of the following indicates the patient is having difficulty with this change in body image? The patient is asking many questions. The patient continues to rely on the nurse to change the ostomy pouch. The patient holds a gauze pad over the stoma while cleaning the peristomal skin. The patient is willing to look at the stoma.

The patient continues to rely on the nurse to change the ostomy pouch

If a patient had to have part of the colon (large intestine) removed, which of the following may result? The patient could experience an acid-base imbalance. The patient could experience increased amounts of mucus in the stool. The patient could experience fluid volume overload with increased absorption. Once healed, it would be unlikely for the patient to experience any alteration in elimination.

The patient could experience an acid-base imbalance

A nurse is admitting a patient to the unit. The nurse is aware that the patient is at increased risk for constipation if the following are present in the patient's health history or admission assessment: (Select all that apply.) The patient is an elderly woman. The patient reports rare laxative use. The patient takes opioids for chronic back pain. The patient eats whole grains, raw fruits, and green leafy vegetables. The patient takes daily iron and calcium supplements. The patient reports daily exercise and remains active.

The patient is an elderly woman The patient takes opioids for chronic back pain The patient takes daily iron and calcium supplements

The nurse is caring for a patient who had knee replacement surgery 5 days ago. The patient's knee appears red and is very warm to the touch. The patient requests pain medication. Which of the following would be a correct explanation of what the nurse has assessed? These are expected findings for this postoperative period. The patient is becoming dependent on pain medication. The nurse should observe the patient more closely for wound dehiscence. The patient is demonstrating signs of a postoperative wound infection.

The patient is demonstrating signs of a postoperative wound infection

A patient was diagnosed with a urinary tract infection. The patient has been drinking fruit juice and has increased his intake of fluids but has failed to take his antibiotic as prescribed because it caused gastric upset. Three days later, the patient presents to the clinic with fever, malaise, nausea, and vomiting. What might you suspect? The patient probably has the flu. The patient may now have a systemic infection. The patient is displaying signs of a localized infection. The patient is experiencing an allergic response to his medication.

The patient may now have a systemic infection

Which of the following patients is most likely to experience some difficulty with effective coughing? The elderly patient who had outpatient foot surgery. The middle-age man who is postoperative for knee arthroplasty. The patient who is postoperative for abdominal surgery. The patient who preoperatively practiced cascade coughing.

The patient who is postoperative for abdominal surgery

The nurse is caring for four individuals. Which patient would be most at risk for infection? The patient who is receiving immunosuppressive medication. The patient who is unable to shower without assistance. The patient with a history of a latex allergy. The patient who exercises daily in a swimming pool.

The patient who is receiving immunosuppressive medication

Which of the following patients should be assessed for a worsening clinical situation? The chronic obstructive pulmonary disease (COPD) patient whose pulse oximetry remains the same after oropharyngeal suctioning. The patient with absence of adventitious lung sounds on inspiration and expiration. The patient who demonstrates less drooling after being suctioned. The patient with presence of blood in the secretions.

The patient with presence of blood in the secretions

Why might the nurse choose not to apply a pair of prescribed elastic stockings to a patient's legs? The patient has become fully ambulatory. The patient's skin is irritated. The patient says they are too tight. The patient will have a scheduled bath in a few hours.

The patient's skin is irritated

Which of the following indicates a reason for notifying the health care provider to get an order for removal of an indwelling catheter? The patient states, "My bladder feels so full, it is starting to hurt!" The catheter has been in place for 3 days. The patient's urine appears cloudy with a foul odor. The patient is drinking less than 1500 mL of fluids daily.

The patient's urine appears cloudy with a foul odor

The nurse is reviewing enema administration with nursing assistive personnel (NAP). Which of the following statements by the NAP indicates further instruction is necessary? "The rectal tube of an enema should be inserted 5 to 7.5 cm (2 to 3 inches) into the rectum of an adolescent." "The rectal tube of an enema should be inserted 2.5 to 3.75 cm (1 to 1 ½ inches) into the rectum of an infant." "The rectal tube of an enema should be inserted 7.5 to 10 cm (3 to 4 inches) into the rectum of an adult." "The rectal tube of an enema should be inserted 5 to 7.5 cm (2 to 3 inches) into the rectum of a child."

The rectal tube of an enema should be inserted 5 to .5 c (2 to 43 inches) into the rectum of an adolescent

A nurse is obtaining a patient's medical history when he states, "I am HIV positive because I shared needles with a friend who is also HIV positive." The friend would be considered: The vehicle or route of transmission. The infectious agent. The reservoir. The susceptible host.

The resevoir

The NAP is applying a condom catheter to the patient. The patient asks, "What is the purpose of the skin preparation solution?" The NAP correctly responds: "It is used before condom sheath application as an adhesive to hold the condom catheter on." "It is an antiseptic to clean pathogens from the area before applying the condom catheter." "The skin preparation solution prevents skin irritation and should be dry before the condom catheter is applied." "The skin preparation solution helps the condom catheter to go on more easily, reducing friction, and should still be wet when the sheath is applied."

The skin preparation solution prevents skin irritation and should be dry before the condom catheter is applied

An adult patient complains of cramping during the administration of an enema. What could be a possible cause? (Select all that apply.) The solution was instilled too rapidly. The patient was placed in Sims' position. The enema bag was held too low during the infusion. The enema solution was too cold. The lubricated rectal tip was inserted 3 to 4 inches.

The solution was instilled too rapidly The enema solution was too cold

The nurse is pouching a new ostomy. The patient asks why the nurse always measures the size of the stoma, stating, "Don't you remember how large to cut the opening?" Which of the following would be an inaccurate response by the nurse and would require correction? "The stoma typically increases in size with the passage of time." "It is important to have the correct size for a proper fit and protection of your skin." "Too large an opening will permit fecal drainage to come in contact with peristomal skin, causing irritation." "The stoma will shrink and reach usual stoma size in about 6 weeks."

The stoma typically increases in size with the passage of time

Which of the following may indicate an increased risk for wound dehiscence? There is an increase in serosanguineous drainage from the wound. It is within the first 24 to 48 hours after surgery. The patient holds a pillow over the abdomen whenever coughing. There is a small amount of serous drainage noted on the dressing.

There is an increase in serosanguineous drainage from the wound

A patient had an indwelling catheter for 3 weeks. The patient had the catheter removed 3 hours ago and now complains of having to go to the bathroom frequently and that it is painful to void. Which instruction is appropriate for the nurse to give the patient? "This is a normal occurrence after having a catheter in place for more than several days." "It sounds like you have a UTI. I will notify your health care provider." "I will need to inspect your perineal area and wash and dry the area." "If these symptoms continue, I will notify your health care provider to see if we can reinsert the catheter."

This is a normal occurrence after having a catheter in place for more than several days

A patient returned from urological surgery with closed continuous bladder irrigation. The patient's vital signs are within normal limits. The patient's wife voices concern regarding the "bloody-red" appearance of the drainage. What is the nurse's best response? "This is normal at this time; the drainage will become lighter and appear blood tinged in 2 to 3 days." "I will notify the health care provider immediately of this unexpected finding." "You don't need to worry, we are doing everything possible for your husband. He is in good hands." "What you are seeing in the drainage bag really isn't blood, but rather a type of drainage."

This is normal at this time; the drainage will become lighter and appear blood tinged in 2 to 3 days

The patient is to have intermittent irrigation of a double-lumen urinary catheter. The patient asks why the nurse is kinking the drainage tubing and putting a rubber band on it. What is the nurse's best response? "This will prevent air from entering your bladder which could cause bladder spasms." "This prevents the irrigating solution from going down into your drainage bag rather than into your bladder." "Clamping the drainage tubing helps your bladder to maintain muscle tone so you will not become incontinent." "Clamping the drainage tubing is a safety measure to prevent bacteria from the drainage bag to enter your bladder during irrigation."

This prevents the irrigating solution from going down into your drainage bag rather than into your bladder

The nurse instructs the patient that the health care provider has ordered an enema. The patient states, An enema! I m not constipated. What are other possible reasons for the order? (Select all that apply.) To prevent laxative misuse. To administer a medication. Preparation for a diagnostic procedure. To increase fluid intake. Preparation for surgery.

To administer a medication Preparation for a diagnostic procedure Preparation for surgery

When brushing the teeth of an unconscious patient, why is the toothbrush held so that its bristles are at a 45-degree angle to the gum line? To give the nurse a firm grip on the brush handle To ensure that the bristles reach all tooth surfaces To reduce pressure on sensitive oral tissues To allow the bristles to reach beneath the gum line

To allow the bristles to reach beneath the gum line

The nurse listens for bowel sounds before administering an enema. The patient asks, "Why are you listening to my abdomen?" The nurse's accurate response is: "To determine the presence of bowel sounds, which indicates you will be able to hold the solution." "To determine which position I should place you in for administration of the enema." "To determine the presence of bowel sounds, which indicates the intestines are working." "To determine the amount of enema solution needed."

To determine the presence of bowel sounds, which indicates the intestines are working

A health care provider has ordered an indwelling catheter to be inserted for bedside drainage. Which of the following is NOT an expected indication for catheterization with an indwelling catheter? Preoperative status. To determine urinary retention. To obtain accurate urinary output in a critically ill patient. To allow a pressure ulcer on the coccyx to heal in a patient with urinary incontinence.

To determine urinary retention

When removing a gown worn as personal protective equipment (PPE) while caring for a patient in isolation, why does the nurse avoid touching the outside of the gown? To prevent touching contaminated material with unprotected hands To fold the gown correctly for reuse by the same nurse To protect the nurse's uniform To ensure that the gown can be reused

To prevent touching contaminated material with unprotected hands

Which of the following are functions of dressings? (Select all that apply.) To promote hemostasis. To keep the wound bed dry. Wound debridement. To prevent contamination. To increase circulation.

To promote hemostasis Wound debridement To prevent contamination

The patient asks the nurse what the purpose is for his Hemovac drain. What is the nurse's best response? "To reduce the need for frequent dressing changes." "To provide suction to remove and collect drainage from your wound to help it heal." "To accurately determinine fluid loss and whether your fluids need to be increased." "To prevent infection and crust formation at the wound site."

To provide suction to remove and collect drainage from your wound to help it heal

Why is it important for the nurse to set the correct flow rate for a patient to whom oxygen is prescribed? To provide the correct amount of oxygen to the patient To prevent any adverse reaction to the prescribed oxygen therapy To minimize the risk of combustion during oxygen delivery To ensure the therapeutic effects of oxygen therapy

To provide the correct amount of oxygen to the patient

What is the primary reason an unconscious patient is placed in the side-lying position when mouth care is provided? To prevent possible musculoskeletal injury To reduce the risk of aspiration To reduce plaque buildup in the mouth To make the oral cavity easily accessible

To reduce the risk of aspiration

Why does a wound bed need to stay moist? To determine if the area has reactive hyperemia. To prevent excessive fluid loss from the body. To decrease patient discomfort. To support healing by enabling granulation tissue to grow.

To support healing by enabling granulation tissue to grow

A patient has a diagnosis of Clostridium difficile. What is most important for the nurse to convey to the NAP regarding this patient's care? To use an alcohol-based hand rub after removing gloves. To avoid caring for other patients with C. difficile to prevent cross contamination. To wash hands with soap and water before and after caring for patients with C. difficile. To wear an N95 mask when in the patient's room.

To wash hands with soap and water before and after caring for patients with C-diff

A 73-year-old patient was admitted with severe respiratory distress secondary to pneumonia. She has a long history of smoking, which she recently stopped. On arrival she was placed on continuous pulse oximetry, and an endotracheal tube was inserted for mechanical ventilation. She is heavily sedated. She is receiving an intravenous infusion at 100 mL per hour. Intravenous fluids may affect this patient's respiratory status. True False

True

A 73-year-old patient was admitted with severe respiratory distress secondary to pneumonia. She has a long history of smoking, which she recently stopped. On arrival she was placed on continuous pulse oximetry, and an endotracheal tube was inserted for mechanical ventilation. She is heavily sedated. This patient is at risk for airway occlusion. True False

True

A 73-year-old patient was admitted with severe respiratory distress secondary to pneumonia. She has a long history of smoking, which she recently stopped. On arrival she was placed on continuous pulse oximetry, and an endotracheal tube was inserted for mechanical ventilation. She is heavily sedated. This patient's risk factors for respiratory problems include history of smoking, her illness, and her age. True False

True

Healing by primary intention is expected when the edges of a clean surgical incision are sutured or stapled together, tissue loss is minimal or absent, and the wound is uncontaminated by microorganisms. True False

True

The nurse desires to suction the patient's left main-stem bronchus. In what position should the patient be placed? Keep the patient's head in a neutral position and rotate the catheter counter-clockwise on insertion. Keep the patient's head in a neutral position and rotate the catheter clockwise on insertion. Turn the patient's head to the left. Turn the patient's head to the right.

Turn the patient's head to the right

The nurse inspects all wounds for signs of infection. When might a contaminated or traumatic wound show signs of infection? Up to 5 days after injury. During the first 24 to 48 hours after injury. Two to three days after injury. Five to seven days after injury.

Two to three days after injury

A patient is scheduled to have an ileostomy. The patient asks, "Will I always have to wear a pouch?" What is the nurse's best response? "An ileostomy generally results in formed stool, so you may not have to wear a pouch at all times." "An ileostomy can be regulated by inserting a catheter and emptying it as needed, so a pouch is unnecessary." "Unless an internal pouch is surgically created, the effluent of an ileostomy is very liquid and must be pouched at all times." "It really depends on your diet. Some patients are able to regulate their ileostomy by performing daily irrigations, usually in the morning after breakfast."

Unless an internal pouch is surgically created, the effluent of an ileostomy is very liquid and must be pouched at all times

The nurse is caring for a patient who underwent major abdominal surgery 24 hours ago. The 72-year-old male patient is weak and lethargic because of large doses of medication for pain control. After noting audible gurgling on inspiration and expiration, the nurse completes a respiratory assessment. Which assessment parameters indicate the need for oral suction? (Select all that apply.) Unusual restlessness. Gagging. Gurgling and adventitious lung sounds. Evidence of emesis in the mouth. Persistent coughing that fails to clear airway. Persistent complaints of pain. Weakness and lethargy accompanied by drooling.

Unusual restlessness gagging gurgling and adventitious lung sounds evidence of emesis in the mouth persistent coughing that fails to clear airway weakness and lethargy accompanied by drooling

The nurse is planning to insert an oral airway into an unconscious patient before performing mouth care. In which direction is the airway initially inserted into the patient's mouth? With the curve angled toward the patient's right cheek Upside down, or with the curve facing up With the curve angled toward the patient's left cheek Right side up, or with the curve facing down

Upside down, or with the curve facing up

Which of the following regarding removal of the old dressing on a surgical incision are accurate? (Select all that apply.) Tape should be pulled parallel to the skin in a direction away from the incision. While wearing clean gloves, remove the dressing layers all at one time and discard. Use caution to avoid tension on any drains that are present. Wear sterile gloves to remove old dressing. If dressing is over a hairy area, remove tape in the direction of hair growth.

Use caution to avoid tension on any drains that are present If dressing is over a hairy area, remove tape in the direction of hair growth

The nurse is bathing a patient who is unconscious. What should the nurse do to ensure safe care of the patient's eyes? Avoid closing the patient's eyes. Use eye patches or shields taped in place. Tape the patient's eyelids closed. Remove eye crusts with soapy water.

Use eye patches or shields taped in place

The NAP complains of his hands hurting and skin being chapped. What would be appropriate suggestions for the NAP? (Select all that apply.) Use hand lotion from an individual use container. Decrease the frequency of hand hygiene until healed. Wear clean latex-free gloves at all times. Be sure to rinse and dry hands thoroughly. Avoid excessive amounts of soap or antiseptic.

Use hand lotion from an individual use container Be sure to rinse and dry hands thoroughly Avoid excessive amounts of soap or antiseptic

The nurse is teaching the nursing assistive personnel (NAP) in a nursing home about daily routine measures to reduce the incidence of pressure injuries within the agency. Which of the following should the nurse include in the teaching? (Select all that apply.) Rubbing reddened bony prominences. Using a turn sheet to reposition patients. Use of pillow bridging when needed. Turning patients at least every 2 hours. Positioning patient in the 30-degree lateral position. Decreasing patients' fluid intake to decrease incidence of incontinence.

Using a turn sheet to reposition patients Use of pillow bridging when needed Turning patients at least every 2 hours Positioning patient in the 30-degree lateral position

The nurse is performing hand hygiene. Which would be an inappropriate action? (Select all that apply.) Keeping the hands and forearms lower than elbows. Using friction for 10 seconds in a vertical motion. Turning the faucet off with a clean, dry paper towel. Using hot water to rinse the hands after lathering. Drying hands from wrists to fingers with a paper towel.

Using friction for 10 seconds in a vertical motion Using hot water to rinse the hands after lathering Drying hands from wrists to fingers with a paper towl

The nurse is preparing to give a patient a bath using a disposable bath-in-a-bag product. What should the nurse do first? Remove the patient's gown. Obtain a washbasin. Gather towels and washcloths. Warm the product in the microwave.

Warm the product in the microwave

Why are the hands rinsed with the fingertips held lower than the wrist? Water flows from the least to the most contaminated area, rinsing microorganisms into the sink. To keep the sleeves from getting wet. It is necessary to ensure that all surfaces of the hands, including under the nails, are cleansed. To loosen and remove dirt and bacteria.

Water flows from the least to the most contaminated area, rinsing microorganisms into the sink

A discussion is taking place on the unit regarding the application of lubricant to the suction catheter before passing it through the nasal passage. Which statement is accurate? "Water-soluble lubricant should be used because oil based lubricants increase the risk for aspiration and pneumonia." "If the patient's fluid status is sufficient, lubricating the catheter is unnecessary." "Petroleum jelly can be used to lubricate the catheter as long as the patient is not on oxygen via nasal cannula." "Applying water-soluble lubricant to the suction catheter ensures that it is working properly prior to oropharyngeal or nasotracheal suctioning."

Water-soluble lubricant should be used because oil based lubricants increase the risk for aspiration and pneumonia

An NAP asks what an example would be of using standard precautions. The nurse is correct to respond: Wearing clean gloves when emptying a bedpan. Placing an "isolation precautions" sign on the patient's door to alert any visitors. Collecting a sputum specimen to determine if an infection is present. Wearing gloves and a mask whenever it is known that a patient has a communicable illness.

Wearing clean gloves when emptying a bedpan

The nurse is assisting a patient with a tub bath. After the patient has been safely positioned in the tub, he tells the nurse, "I'll call you when I'm done." What is the nurse's best response? All right. Just holler when you're ready, and I'll come and help you get out of the tub. I'll be back in 15 minutes. That should enough time for you to finish up. Well, I'll check back with you in about 5 minutes to see if you need anything. That's not safe. I'll wait right outside the door for you to finish.

Well, I'll check back with you in about 5 minutes to see if you need anything

A 53-year-old patient is being treated for hypertension and a history of thrombophlebitis (blood clots). She comes to the clinic complaining, "I have to get up all night to go to the bathroom, and I think my urine looks orange!" What is the nurse's best response? "It sounds like you may have a urinary tract infection." "Your high blood pressure is adversely affecting your kidneys." "Have you tried to restrict your fluid intake?" "What medications are you taking and when?"

What medication are you taking and when?

When are sterile gloves necessary? When performing postmortem care. When performing a sterile procedure. If the patient is placed on isolation. If blood or body fluids are present.

When performing a sterile procedure

Identify prevention strategies for pressure injuries. (Select all that apply.) Reposition patient at least every 4 hours; use a documented schedule. When the patient is in the side-lying position in bed, use the 30-degree lateral position. Place patient on a pressure-reducing support surface. Maintain the head of the bed at 45 degrees. Massage reddened bony prominences. Oral supplements should be instituted if the patient is found to be undernourished.

When the patient is in the side-lying position in bed, use the 30-degree lateral position Place patient on a pressure-reducing support surface Oral supplements should be instituted if the patient is found to be undernourished

When should wound drainage be cultured? When there is a change in color, amount, or odor of drainage. If the patient complains of pain. When the drain is removed. If the nurse empties the drainage evacuator without applying sterile gloves.

When there is a change in color, amount, or odor in drainage

It is suspected that a patient is developing a wound infection. Which assessment data would support this conclusion? (Select all that apply.) White blood cell count 13,000 mm3 (elevated). Temperature 100.3° F (37.94° C). Wound edges pink to normal skin color. Foul odor noted from previous dressing. Yellow-tinged drainage. Increased complaints of pain at wound site.

White blood cell count 13,000 mm3 (elevated) Temperature 100.3F (37.94C) Foul odor noted from previous dressing Yellow-tinged drainage Increased complaints of pain at wound site

A postoperative diabetic patient had an exploratory laparotomy (incision in the abdomen) 5 days ago. The patient's history indicates obesity with a body mass index (BMI) of 32 and smoking 1 pack/day. Based on this information, the nurse understands the patient should be observed for: Developing a blood clot. Developing a fistula. Wound dehiscence. Hemorrhage.

Wound dehiscence

Which of the following is a correct description of glove removal? You pull the gloves off by the fingertips and discard them in a proper receptacle. You grasp the inside of one glove with the other gloved hand, pull the glove off, and discard it in a proper receptacle. The remaining glove is removed by placing the fingers of the bare hand outside the cuff, pulling the glove off, and discarding it in a proper receptacle. Correct! You grasp the outside of one cuff with the other gloved hand and pull the glove off, turning it inside out, and place it in gloved hand. Take fingers of bare hand and tuck inside remaining glove cuff against the skin. Peel glove off inside out and over the previously removed glove. Discard both gloves in receptacle. You slide the gloved fingers of the dominant hand under the inside cuff of the nondominant hand and pull the glove off and discard. Then you slide the fingers of the nondominant hand under the cuff of the dominant hand and pull the glove off and discard.

You grasp the outside of one cuff with the other gloved hand and pull the glove off, turning it inside out, and place it in the gloved hand. Take gingers of bare hand and tuck inside remaining glove cuff against the skin, Peel glove off inside out and over the previously removed glove. Discard both gloves in receptacle.

The nurse is instructing a patient on how to change a transparent dressing. Which statement, if made by the nurse, requires correction? "The old dressing may be removed while wearing clean gloves. Remove in direction of hair growth and toward the center. Remove disposable gloves pulling them inside out over the soiled dressing and dispose of properly." Correct! "You will want to remove your gloves to prevent the transparent dressing from sticking to them. Remove the paper backing of the transparent dressing and firmly stretch it over the wound to prevent wrinkling." "When the dressing change is completed, be sure to wash your hands. A transparent dressing is beneficial because it maintains a moist environment, which aids wound healing; allows you to examine the wound without having to remove the dressing; and conforms well to body contours." "You will need to apply new gloves after you open your supplies and before you clean the wound. Make sure the area around the wound is dry before applying a new transparent dressing."

You will want to remove your gloves to prevent the transparent dressing from sticking to the,. Remove the paper backing of the transparent dressing and firmly stretch it over the wound to prevent wrinkling

Which of the following patients are at risk for developing an infection? (Select all that apply.) A patient in a private room. A patient who has an early discharge from the hospital. A patient receiving chemotherapy. A patient with an IV. A patient with a chronic respiratory disease receiving steroid therapy.

a patient receiving chemotherapy a patient with an IV a patient with a chronic respiratory disease receiving steroid therapy

When is it acceptable to use antiseptic hand rub rather than soap and water? (Select all that apply.) After adjusting a nasal cannula on a patient. After removing gloves after changing a wound dressing. When the nurse's hands are cracked from frequent hand hygiene. After moving patient's belongings on the bedside table. After the patient develops a skin tear and blood is on the nurse's hand. When the patient has been diagnosed with C. difficile.

after adjusting a nasal cannula on a patient After removing gloves after changing a wound dressing After moving patient's belongings on the bedside table

When teaching a patient about wound healing, what should the nurse tell the patient? Inadequate nutrition delays wound healing and increases risk of infection. Chronic wounds heal more efficiently in a dry, open environment, so leave them open to air when possible. Long-term steroid therapy diminishes the inflammatory response and speeds wound healing. Fat tissue heals more readily because there is less vascularization.

inadequate nutrition delays wound healing and increases risk of infection

The NAP reports to the nurse a 65-year-old patient s blood pressure is 160/98. What is the appropriate initial response of the nurse? Document this as a normal finding in an elderly adult. Ask the NAP if the patient is nauseous. Instruct the NAP to obtain a full set of vital signs. Assess the patient s blood pressure.

Assess the patient's blood pressure

A patient who weighs 200 lbs. needs to be moved up in bed with the aid of a friction-reducing device. The nurse will prepare for this move by assembling how many caregivers? At least three The nurse can carry out this move without assistance A minimum of two None, since the device does all the lifting during the move

At least 3

Whenever there is an alteration in the radial pulse rate, rhythm, or amplitude, the nurse should initially do which of the following? Reassess the radial pulse for 30 seconds. Auscultate the apical pulse for quality and rate. Check the carotid pulses one side at a time. Check the radial pulse on the opposite side.

Auscultate the apical pulse for quality and rate

A nursing student is assigned to take the vital signs on a patient and finds the radial pulse to be irregular. What action should the nursing student take? Check the patient's previous pulse reading. Wait 15 minutes and reassess the pulse. Auscultate the patient's apical pulse. Ask a fellow student to assess the pulse.

Auscultate the patient's apical pulse

Neck flexion and extension should be: 30 degrees 90 degrees 70 degrees 45 degrees

45 degrees

What is the normal pulse range for an adult? 90 to 140 beats per minute. 50 to 80 beats per minute. 120 to 160 beats per minute. 60 to 100 beats per minute.

60 to 100 beats per minute

The nurse was assigned to care for five patients. Which of the following vital sign measurements would be cause for concern? (Select all that apply.) Correct! 65-year-old with blood pressure of 140/90 22-year-old with heart rate of 90 beats/minute 75-year-old with pulse oximetry of 88% on room air 88-year-old with temperature of 96.8° F (36° F) 8-year-old with respiratory rate of 24 breaths/minute

75-year-old with pulse oximetry of 88% on room air

If a 52-year-old patient has a normal temperature, what range should the patient's temperature fall within? 96.8-98.6 °F (36-37 °C) Correct! 96.8-100.4 °F (36-38 °C) 37-39 °C (98.6-102.2 °F) 35-36 °C (95-96.8 °F)

96.8-100.4F (36-38C)

A patient was brought to the emergency department following a motor vehicle accident. He appears drowsy, but will arouse to his name being called. He is bleeding profusely from an injury to his leg. What would the nurse expect his vital signs to be? 98.6°F (37°C), 84, 20, 120/80 97.8°F (36.5°C), 110, 24, 80/40 99.0°F (37.2°C), 88, 16, 130/80 100.4°F (38°C), 76, 24, 140/90

97.8°F (36.5°C), 110, 24, 80/40

Which patient is at high risk for for the pulse oximetry alarm to sound? A patient with a continuous pulse oximetry reading of 84%. A patient who is receiving oxygen via face mask. A patient who has an intermittent pulse oximetry reading of 95%. A patient with a heart rate of 64 beats per minute.

A patient with a continuous pulse oximetry reading of 84%

Which patient is most at risk of developing permanently impaired mobility? An 11-year-old boy who sustained a fractured pelvis during a fall from his tree house A 79-year-old man recovering from surgery to release a contracture of the connective tissue in his hand A 72-year-old woman hospitalized for anemia associated with diabetic nephropathy (kidney disease) A 55-year-old woman with mental illness who had become malnourished

A 72-year-old woman hospitalized for anemia associated with diabetic nephropathy (kidney disease)

Which of the following patients is at greatest risk for experiencing a fall? A confused patient with a history of a previous fall. A patient who ambulates by holding onto furniture. A recently admitted patient. A patient who wears glasses to read.

A confused patient with a history of a previous fall

Which of the following patients would be considered hypertensive after having two or more consistent readings of these values? An African-American patient with a systolic BP of 100. A football player with a diastolic BP of 94. An elderly patient with a systolic BP of 88. A pregnant woman with a diastolic BP of 67.

A football player with a diastolic BP of 94

The nurse is planning tasks for the day. Which of the following patients would require repositioning at this time? (Select all that apply.) A patient in correct body alignment who was turned 2 hours ago. A patient who has been sitting in a chair for 10 minutes watching television. A comfortable patient with paraplegia who has been sitting in a chair for 30 minutes. A patient who was repositioned for comfort 30 minutes ago after being moved up in bed.

A patient in correct body alignment who was turned 2 hours ago A comfortable patient with paraplegia who has been sitting in a chair for 30 minutes

Which of the following patients should be allowed to lie back down? A patient who was just transferred to a chair and states she was more comfortable in bed. Health care provider's orders are to be up in chair twice daily. A patient whose blood pressure was 120/80 prior to transfer and is now 112/78. A patient who complains of feeling dizzy and slightly nauseous when sitting on the bedside. A patient whose blood pressure was 110/70 prior to transfer and is now 125/80.

A patient who complains of feeling dizzy and slightly nauseous when sitting on the bedside

In which of the following patients would the nurse expect to find a decrease in pulse rate? (Select all that apply.) A patient who received morphine for pain. A student who is getting ready to take an exam. A patient returning from the operating room. A patient who experienced a bleeding episode. A newborn following a heelstick.

A patient who received morphine for pain A patient returning from the operating room

For which patient should you avoid using a leg pressure cuff (thigh cuff) to assess BP? A patient who is a double arm amputee following a motor vehicle accident. A patient with a deep vein thrombosis (blood clot, usually in the lower extremities). A patient with a history of a right-sided cerebrovascular accident (stroke). A patient with an arteriovenous shunt located in the forearm for hemodialysis.

A patient with a deep vein thrombosis (blood clot, usually in the lower extremities)

For which patient would a tympanic thermometer be the preferred thermometer to use? A marathon runner who developed weakness during the race. A tachypneic patient who is receiving oxygen by nasal cannula. A pediatric patient who had tubes surgically placed in the ears. A newborn that requires continuous temperature monitoring.

A tachypneic patient who is receiving oxygen by nasal cannula

Which of the following patients would require frequent assessment of their temperature? (Select all that apply.) A young adult with a white blood count of 15,000/mm3. An adult female in the recovery room following a hysterectomy. A patient receiving a blood transfusion for chronic anemia. A child who is below the normal height and weight for his age. An elderly patient who needs assistance with feeding and dressing.

A young adult with a white blood count of 15,000/mm3 An adult female in the recovery room following a hysterectomy A patient receiving a blood transfusion for chronic anemia

How can the nurse best obtain an accurate measurement of a patient's respiratory rate? Inform the patient when monitoring his or her respirations. Correct! Continue to act as though taking the patient's pulse while discretely observing the rise and fall of the patient's chest. Assess the respirations while the patient is talking. Auscultate the lung sounds, asking the patient to take a deep breath in through the nose and exhale slowly through the mouth.

Continue to act as though taking the patient's pulse while discretely observing the rise and fall of the patient's chest

Which action would decrease a patient's pain before a transfer with a hydraulic lift? Explain the procedure to the patient before beginning the transfer. Postpone the transfer if the patient reports having physical pain or anxiety before the transfer. Administer a prescribed analgesic 30 to 60 minutes before the transfer. Stop the transfer if the patient expresses or displays physical signs of pain.

Administer a prescribed analgesic 30 to 60 minutes before the transfer

Which person would be expected to have the lowest body temperature? An 80-year-old who walked half a mile. A child playing softball. A 16-year-old who ran 1 mile. A toddler who is febrile.

An 80 year old who walked half a mile

Who would the nurse expect to have the highest body temperature reading? An elderly African-American male. An adult female who is walking. A preterm baby who is sleeping. A teenager playing video games.

An adult female who is walking

Which of the following should the nurse report to the health care provider? An elderly male with a temperature of 96.8°F (36°C). A young adult with a blood pressure of 110/70. An adult patient with a heart rate of 55. A newborn with a respiratory rate of 40.

An adult patient with a heart rate of 55

Which of the following patients would require follow-up? A child with a respiratory rate of 20 breaths per minute. An adolescent with a respiratory rate of 16 breaths per minute. A newborn with a respiratory rate of 40 breaths per minute. An adult with a respiratory rate of 10 breaths per minute.

An adult with a respiratory rate of 10 breaths per minute

What is an increased thoracic curvature, common in older adults, called? Kyphosis Scoliosis Swayback Lordosis

Kyphosis

The student nurse is unsure of the BP measurement. What should the student nurse do first? Wait 30 seconds and repeat the measurement on the same arm. Assess the BP in the other arm. Get the nurse to assess the BP. Determine if the patient received an antihypertensive medication.

Assess the BP in the other arm

When preparing for safe patient transfer using a hydraulic lift, the nurse performs which action first? Arranges for at least three healthcare personnel to assist in the transfer Applies clean gloves Makes sure the patient agrees to the intervention Assesses the patient for weakness, dizziness, or postural hypotension

Assess the patient for weakness, dizziness, or postural hypotension

When preparing to move a patient in bed, what will the nurse do first? Assemble adequate help to move the patient. Assess the patient's ability to help with moving. Decide on the most effective means of moving the patient Determine the patient's weight.

Assess the patient's ability to help with moving

Which condition is not associated with venous stasis, part of Virchow's triad? Obesity Anxiety Immobility Pregnancy

Anxiety

Which of the following techniques is used to assess muscle strength in a patient? Observe the patient at rest. Percuss the muscle. Palpate the muscle. Apply an opposing force or resistance.

Apply an opposing force or resistance

When using a hydraulic lift to transfer a patient from the bed to a chair, when does the nurse turn off the check valve? After the patient crosses the arms over the chest After the patient's eyeglasses are removed As soon as the patient has been placed in the chair When the nurse removes the straps

As soon as the patient has been placed in the chair

The nurse is preparing to initiate ambulation with a patient who is recovering from a stroke. What information will help the nurse determine how far to walk? Review the medical record to see how far the patient has walked during the past several therapeutic ambulations. Ask the patient how far she would like to go. Review the health care provider's order. Review the records of other patients who are at a similar point in their stroke rehabilitation.

Ask the patient how far she would like to go

The NAP is preparing to measure a patient's vital signs. The patient reports having eaten a bowl of warm soup. The NAP asks the RN what he should do. What is the best response? "Change to the red thermometer probe and take the patient's temperature rectally." "Take the patient's temperature using the axillary route and when you record the reading, add 1°F." "Since the soup was not hot, go ahead and take the patient's temperature." "Ask the patient not to eat, drink, or smoke for 20 minutes and then assess the patient's oral temperature."

Ask the patient to not eat, drink, or smoke for 20 minutes then assess the patient's oral temperature

The nurse decides to collect the patient's temperature orally using an electronic thermometer. Choose the equipment to be used. (Select all that apply.) Red probe electronic thermometer. Chemical oral thermometer. Blue probe electronic thermometer. Tympanic thermometer. Patient data recording sheet and a pen. Thermometer cover. Lubricant. Watch with second hand. Tissue. Chemical external thermometer.

Blue probe electronic thermometer Patient data recording sheet and a pen Thermometer cover

Which of the following findings in a musculoskeletal assessment would be considered abnormal? (Select two) Bogginess Symmetry Nodules

Bogginess Nodules

Which of the following are appropriate safety measures for the use of a wheelchair? (Select all that apply.) Brakes on both wheels are locked when the patient is being transferred into the wheelchair. Brakes on the side nearest the bed are locked when the patient is being transferred into the wheelchair. Keep footplates lowered for transfer into the wheelchair. Back the wheelchair into and out of an elevator. Seat patient in wheelchair with buttocks against back of seat.

Brakes on both wheels are locked when the patient is being transferred into the wheelchair Back the wheelchair into and out of an elevator Seat patient in wheelchair with buttocks against back of seat

The nurse walking down the hospital corridor glances into the patient's room and sees the patient's feet and legs sticking out from the bathroom entrance. The nurse immediately goes into the room and determines that the patient has fallen. What actions should be taken? (Select all that apply.) Call for assistance. Assess for injury. Notify the health care provider. Avoid moving the patient until the health care provider arrives. Assess the situation for precipitous factors (e.g., hypotension, slippery footwear, etc.). Apply a restraint after returning the patient to bed. Fill out an agency occurrence or sentinel event report.

Call for assistance Assess for injury Notify the health care provider Assess the situation for precipitous factors (e.g., hypotension, slippery footwear, etc.). Fill out an agency occurrence or sentinel event report

What is an appropriate nursing intervention for an adult patient with a respiratory rate of 30 breaths per minute? (Select all that apply.) Tell the patient their breaths are being counted so the patient will breathe slower. Count the respiratory rate again for a full 60 seconds (1 minute). Assess physiologic factors that may be causing the patient to breathe so fast. Administer a bronchodilator that will decrease the respiratory rate. Record this normal respiratory rate in the patient's medical record.

Count the respiratory rate again for a full 60 seconds (1 minute) Assess physiologic factors that may be causing the patient to breathe so fast

Which of the following are basic guidelines when assisting a patient with passive range of motion? Each joint is exercised to the point of resistance but not pain. Exercises should be done frequently to lessen pain for the patient. Exercises should be continued until the point of fatigue and pain. Exercises should be performed without the support to each joint.

Each joint is exercised to the point of resistance but not pain

Which patient would it be appropriate for the nurse to delegate vital signs? Patient transferred from ICU. Elderly nursing home resident. New admission to the hospital. Patient with recent complaint of headache.

Elderly nursing home resident

An elderly patient was recently admitted to a medical unit with severe fluid and electrolyte imbalance. His family states that he has periods of confusion. What are some practical precautions the nurse can take to ensure the patient's safety without having to use restraints? (Select all that apply.) Use a security camera to monitor the patient while in bed. Make staff assignments for patients in adjacent rooms. Activate the bed alarm when the patient is in bed. Perform nurse toilet and turn or comfort and safety rounds hourly. Administer IV fluids to reverse fluid imbalance.

Make staff assignments for patients in adjacent rooms Activate the bed alarm when the patient is in bed Perform nurse toiler and turn or comfort and safety rounds hourly

The nurse is having great difficulty hearing any sound when taking a patient's BP. What can the nurse do to increase the ability to auscultate the reading? (Select all that apply.) Ensure the bladder of the cuff is centered 1 inch (2.5 cm) above the brachial artery. Make sure the stethoscope does not touch the patient's clothing or BP cuff. Use the bell side of the stethoscope to auscultate the blood pressure. Use a different stethoscope with longer tubing for improved conduction of sound. Reduce environmental noise by turning off the TV or closing the door. Keep the stethoscope tubing still to avoid extraneous sound. Ensure the chest piece is rotated to the diaphragm side.

Ensure the bladder of the cuff is centered 1 inch (2.5cm) above the brachial artery Make sure the stethoscope does not touch the patient's clothing or BP cuff Reduce environmental noise by turning off the TV or closing the door Keep the stethoscope tubing still to avoid extraneous sound Ensure the chest piece is rotated to the diaphragm side

A patient is admitted to a medical unit with pneumonia. She is able to ambulate on her own to the bathroom. What safety precautions should be taken for this patient? (Select all that apply.) Explain the use of the call light. Keep the bed in the low, locked position. Keep all side rails up when patient is in bed. Place a bedside commode near bed with back to wall. Ensure that the pathway to the bathroom is clear. Keep patient's personal items on the overbed table.

Explain the use of the call light Keep the bed in the low, locked position Ensure that the pathway to the bathroom is clear Keep patient's personal items on the overbed table

The nurse should routinely auscultate the apical pulse with the bell side of the stethoscope, and use the diaphragm side to identify heart murmurs. False. True.

False

Which of the following may increase both rate and depth of respiration? (Select all that apply.) Smoking a cigarette. You Answered Having a pain level rating at 7 on a scale of 0-10. Using a bronchodilator prior to exercise. Correct! Feeling anxious when taking a test. Correct! Walking 1 mile briskly. Incurring a head injury from a motor vehicle accident. Taking an opioid to relieve pain. Correct! Having an addiction problem with amphetamines/cocaine.

Feeling anxious when taking a test Walking 1 mile briskly Having an addiction problem with amphetemines/cocaine

When preparing to move a patient in bed with the help of an assistant, which posture will both caregivers use to ensure their own safety? Stand with the feet together. Stand with the knees locked. Shift the body weight from the back leg to the front leg. Flex the hips and knees.

Flex the hips and knees

The nurse reads the following entry in a patient's health record. The patient has an order for SpO2 every 4 hours. Based on this information, what would be the nurse's best action?01/25/17 0800 Unable to obtain pulse oximetry reading. Attempted X2 fingers of each hand. Patient's fingers cool to touch. Patient states has artificial nails. Patient on 2 L oxygen per nasal cannula. Respirations nonlabored. C. Smith, N.A.P.__ Remove one of the patient's acrylic nails and reattempt obtaining the SpO2. Place the patient's hands under warm running water and reattempt the reading. Have the NAP use a different site, such as the ear lobe, to obtain the SpO2 reading. Nothing further, as the NAP has provided sufficient data regarding patient condition.

Have the NAP use a different site, such as the ear lobe, to obtain the SpO2 reading.

What does the nurse do after attaching the hooks to the holes in the sling on a hydraulic lift? Lower the head of the bed. Have the patient cross the arms over the chest. Elevate the head of the bed. Remove the patient's eyeglasses.

Have the patient cross the arms over the chest

A patient complains of feeling excessively tired. Which statement, if made by the NAP, indicates further instruction is necessary? "I will turn the continuous pulse oximetry alarms off at night so you can sleep." "I can give you a back massage to help you relax before bedtime." "If the finger clip is bothering you, I can attach a probe to your ear." "I will notify the nurse that you need your sleeping medication tonight."

I will turn the continuous pulse oximetry alarms off at night so you can sleep.

The nurse is preparing to delegate the ambulation of a patient with the use of a gait belt to nursing assistive personnel (NAP). Which statement made by NAP requires the nurse to follow up? Correct! I will use the under-axillae technique to help him up to a standing position. I will be sure to put nonskid slippers on the patient before getting him up to ambulate. I will grasp the gait belt in the middle of the patient's back.

I will use the under-axillae technique to help him up to a standing position

Using the image below, please choose the correct BP combination:<IM src="http://www.coursewareobjects.com/objects/nso3e_v1/images/assessment_images/mod1l5q5.gif" Link (Links to an external site.you may need to right click this link for it to open). Image A = 126/76, Image B = 140/90, Image C = 138/84, Image D = 120/80 Image A = 140/90, Image B = 138/84, Image C = 120/80, Image D = 126/76 Image A = 138/84, Image B = 120/80, Image C = 126/76, Image D = 140/90

Image A = 120/80, Image B = 128/76, Image C = 140/90, Image D = 138/84

The patient has a history of a left mastectomy. Where should the nurse take the patient's blood pressure? In the right arm In the left arm In the right leg In the left leg

In the right arm

When assessing the respiratory rate, the nurse has difficulty seeing the patient's chest rise and fall with inspiration and expiration. What is the nurse's best action? Move the patient's arm over their chest and feel the rise and fall of the chest. Remove the patient's gown for better visualization of the patient's chest. Document the inability to visualize inspiration and expiration. Have another nurse assess the patient's respiratory rate.

Move the patient's arm over their chest and feel the rise and fall of the chest

Which of the following situations may affect a patient's vital signs? (Select all that apply.) Moving from lying to standing position. Time of day. Occupation. Isolation precautions. Pain rated as a 7 on 0-10 pain scale.

Moving from lying to standing position Time of Day Pain rated as a 7 on a 0-10 pain scale

The nurse reads the following nurse's note in the patient's health record. What is the priority nursing intervention based on this information?9/21/17 1800 Patient complains of headaches, almost daily, occurring more frequently in the evening. BP 164/98. P. Johnson N.A.P. Inform the patient it is normal to have a higher BP reading in the evening. Administer acetaminophen (Tylenol) to relieve the patient's headache. Instruct the NAP to repeat the BP measurement using a manual cuff. Obtain a complete set of vital signs and gather further assessment data.

Obtain a complete set of vital signs and gather further assessment data

The nurse is getting a patient with right-sided weakness up in a chair. On what side of the bed should the nurse place the chair? On the patient's left side. On the patient's weak side. It doesn't matter because you are assisting the patient. Whichever side the patient prefers.

On the patient's left side

The nurse is helping a patient with hemiparesis take a few steps. A gait belt has been applied. The patient is using a cane. Where should the nurse stand in relation to the patient? On the patient's weak side In front of the patient On the patient's strong side Behind the patient

On the patient's weak side

A patient has been given an opioid analgesic (e.g., morphine) for pain relief. Why does the nurse assess the patient's respiratory rate before administering the next dose? Opioid analgesics may depress rate and depth of respirations. To reduce the addiction potential to unnecessary pain medication. To see if the patient's complaints of pain are supported physiologically. Assessment will provide the patient with a sense of security and reduce anxiety.

Opioid analgesics may depress rate and depth of respirations

Identify the factors that may have an effect on an elderly patient's temperature: (Select all that apply.) Participation in physical therapy exercises. Room temperature. Drinking a cold glass of water. Patient's height. Infection.

Participation in physical therapy exercises room temperature drinking a cold glass of water infection

A healthy 30-year-old male arrives at the clinic for a physical. The nurse is responsible for collecting his vital signs. Which of these can be delegated to NAP? (Select all that apply.) Respiration. BP. Pulse. Temperature. Pulse oximetry.

Respiration BP Pulse Temperature Pulse Oximetry

The nurse notes that a patient's left elbow is resistant to extension and flexion while performing range of motion exercises. What is the appropriate nursing action? Move the joint through the full range of motion exercises. Omit all the range of motion exercises until the health care provider is notified. Inform the health care provider that the patient is uncooperative with exercising. Perform range of motion to the left elbow until resistance is met.

Perform range of motion to the left elbow until resistance is met

The nurse is preparing to transfer a patient with left-sided weakness from the bed to a wheelchair using a transfer belt. Which position would the nurse instruct the patient to assume? Place both feet together on the floor. Place your weaker foot forward and your stronger leg toward the back. Extend both of your legs and feet. Place your stronger leg forward and your weaker leg toward the back.

Place your stronger leg forward and your weaker leg toward the back

A nursing instructor asks what may cause orthostatic hypotension. The nursing student correctly replies: (Select all that apply.) Prolonged bed rest. Hypovolemia. Low body weight. Antihypertensives. Room temperature.

Prolonged bed rest Hypovolemia Antihypertensives

You are taking a patient's BP by using the one-step method. Which of the following is an incorrect step in the sequence for performing this procedure? Listen for the last Korotkoff sound in mm Hg. Completely deflate the cuff and remove it from the patient's arm. Make the patient comfortable. Perform hand hygiene. Document the result. Pump the cuff to 20 mm Hg above the patient's normal diastolic pressure. Release the valve quickly. Observe the needle fall. Identify the onset of the first Korotkoff sound in mm Hg. Perform hand hygiene. Select the appropriate-size cuff. With the patient sitting, place the forearm at heart level, palm up. Provide privacy and explain the procedure. Expose the arm and apply the cuff around the upper arm. Palpate for a brachial pulse. Place the stethoscope in your ears and place the diaphragm over the site of the brachial pulse.

Pump the cuff to 20 mm Hg above the patient's normal diastolic pressure. Release the valve quickly. Observe the needle fall. Identify the onset of the first Korotkoff sound in mm Hg.

A patient lying supine in bed is being transferred to a wheelchair using a transfer belt. Which action would the nurse perform just before moving the patient to the side of the bed? Position the chair so that the patient will move toward his or her stronger side. Raise the head of the bed 30 degrees. Help the patient put on skid-resistant footwear. Place the transfer belt over the patient's clothing.

Raise the head of the bed 30 degrees.

The NAP tells the nurse the patient's pulse oximetry is 85% on room air. What nursing action(s) should the nurse take? (Select all that apply.) Start oxygen at 2 liters per minute by nasal cannula. Reassess the patient's pulse oximetry. Place the patient in the high-Fowler's position. Have the NAP take the patient's vital signs. Assess the patient's respiratory and cardiac status.

Reassess the patient's pulse oximetry Place the patient in the high-Fowler's position Assess the patient's respiratory and cardiac status

The NAP reports that the patient's temperature is 39° C (102.2 °F). Which of the following are appropriate nursing actions? (Select all that apply.) Remove the patient's blankets. Limit the patient's fluid intake. Apply a hyperthermia blanket as ordered. Administer an antipyretic to the patient as ordered. Place the patient's feet in a tub of cool water with ice.

Remove the patient's blankets Administer an antipyretic to the patient as ordered

The nurse is ambulating a patient with a gait belt when he says he feels sick to his stomach. What would the nurse do? Return the patient to the bed or chair (whichever is closer). Help him to the restroom. Ease him to the floor. Encourage the patient to complete the distance of ambulation.

Return the patient to the bed or chair (Whichever is closer)

A patient will be moved up in bed with the use of a friction-reducing device. How will the nurse place this device under the patient? Lift the patient to place the device directly under him or her. Sit the patient up in the bed, and place the device behind the shoulders. Roll the patient from side to side, and place the device under the draw sheet. Remove the draw sheet, and replace it with the device.

Roll the patient from side to side, and place the device under the draw sheet

The nurse has applied a gait belt to a postoperative patient to facilitate ambulation. Within a few feet of the bed, the patient begins to complain of dizziness and leans heavily on the nurse. What would be the nurse's initial response? Slowly lower the patient to the floor. Try to hold the patient up until the dizziness passes. Attempt to sit the patient down on a chair just a few steps away. Call for assistance in a loud but calm voice.

Slowly lower the patient to the floor

Which position is used when applying the sling to transfer a patient from the bed to a chair with a hydraulic lift? Side-lying Supine Prone Sims

Supine

In which position will the nurse place the patient to move him or her up in bed? Sitting in the bed Supine with the head of the bed flat Prone with the head of the bed flat Supine with the head of the bed at a 30-degree angle

Supine with the head of the bed flat

The nurse is unable to obtain a BP reading using an electronic BP machine on a post-operative patient. The machine reads "Error." What priority action should the nurse take? Reattempt using a different electronic BP machine. Notify the health care provider of this change in patient condition. Increase the patient's rate of intravenous (IV) fluids. Take the patient's BP manually using a sphygmomanometer.

Take the patient's BP manually using a sphygmomanometer

Which of the following vital signs recorded for an older adult would be considered acceptable (within normal limits)? Temp 96.8° F (36 °C), P-60, R-18, BP 160/90, O2 sat 93%. Temp 97.0° F (36.1 °C), P-60, R-16, BP 116/78, O2 sat 95%. Temp 98.6 °F (37 °C), P-56, R-20, BP 120/80, O2 sat 91%. Temp 98.0 °F (36.7 °C), P-76, R-22, BP 110/70, O2 sat 88%

Temp 97.0° F (36.1 °C), P-60, R-16, BP 116/78, O2 sat 95%.

Which of the following vital signs are expected for the adult patient who has problems in oxygenation? Temp 97.5° F (36.4 °C), P-76, R-20, BP 110/70, O2 sat 95%. Temp 98.2° F (36.8 °C), P-64, R-16, BP 120/80, O2 sat 96%. Temp 98.6° F (37 °C), P-102, R-28, BP 98/50, O2 sat 85%. Temp 97.9° F (36.6 °C), P-80, R-18, BP 140/90, O2 sat 95%.

Temp 98.6° F (37 °C), P-102, R-28, BP 98/50, O2 sat 85%.

A newborn patient's temperature has been rising rapidly and the baby has been crying. Which of the following thermometers would be the best to use in measuring this patient's temperature? Chemical dot Tympanic Temporal artery Rectal electronic

Temporal Artery

The new NAP is unable to palpate a patient's radial pulse. What could be a possible explanation for this difficulty? (Select all that apply.) The NAP assessed the patient's BP before taking the patient's pulse. The NAP is assessing for a pulse on the thumb side of the wrist. The NAP is assessing for a pulse on the ulnar side of the wrist. The patient was previously reported to have a full, bounding pulse. The NAP is pressing down too hard on the patient's radial site. The NAP failed to auscultate the patient's wrist with a stethoscope.

The NAP is assessing for a pulse on the ulnar side of the wrist The NAP is pressing down too hard on the patient's radial site

Which of the following actions, if made by the NAP, would require intervention and further instruction by the nurse? (Select all that apply.) The NAP uses a blue-tipped electronic probe for assessing a patient's axillary temperature. The NAP wipes the single-use chemical dot thermometer and places it back in the patient's drawer for future use. The NAP inserts the red-tipped electronic thermometer probe into the patient's mouth after applying a probe cover. The NAP pulls the pinna up, back, and out in an adult when inserting the tympanic thermometer. The NAP waits un

The NAP wipes the single-use chemical dot thermometer and places it back in the patient's drawer for future use The NAP inserts the red=tipped electronic thermometer probe into the patient's mouth after applying a probe cover

Identify why a child's respirations might be shallow. The child was running around in the waiting room with her sibling before her name was called. The child's parents are smokers and the lungs are negatively affected by secondhand smoke. The child is in acute pain. The child is anxious about seeing the doctor.

The child is in acute pain

It is 7 a.m. and the nurse takes the vital signs of a postoperative patient and finds his blood pressure is elevated. Which of the following could explain the cause for this alteration in BP? The patient has a temperature of 99.0°F when assessed rectally. The patient has been NPO since midnight before the surgery. The patient complains of pain at a 9 on a 0-10 pain scale. The body is compensating for the cool environment of the surgical suite.

The patient complains of pain at a 9 on a 0-10 pain scale

Why would the nurse ask a physical therapist to perform passive ROM exercises for a patient with lower extremity injuries sustained in a motor vehicle crash? The patient is an older adult or has a chronic condition. The patient has pain exacerbated by exercise. The patient is reluctant to perform the exercises because he is worried about reinjury. The patient has orthopedic trauma.

The patient has orthopedic trauma

Which of the following patients would be at risk for having an alteration in peripheral pulse? (Select all that apply.) The patient who was just informed of a diagnosis of cancer. An elderly patient with Type 1 diabetes who is otherwise healthy. A patient who is receiving bolus IV fluids. A patient with Alzheimer's disease. A patient with peripheral vascular disease.

The patient who was just informed of a diagnosis of cancer A patient who is receiving bolus IV fluids A patient with peripheral vascular disease

The task of pulse assessment could be delegated to the NAP for which of the following patients? (Select all that apply.) An apical pulse of a patient who is to receive a cardiac drug. A femoral pulse following a lower leg amputation. A radial pulse of a patient in the emergency room with chest pain. The temporal pulse of a child. A radial pulse on a patient with a 1200 mL fluid restriction.

The temporal pulse of a child A radial pulse on a patient with a 1200mL fluid restriction

The patient's BP reading is 150/80 mmHg. For this patient, 80 is representative of: (Select all that apply.) The ventricles during contraction. The pulse pressure. The ventricles during relaxation. The systolic pressure. The diastolic pressure. The pulse deficit.

The ventricles during relaxation The diastolic pressure

A teen has come to the health care provider's office because he does not feel well after football practice. His temperature is 102°F (38.9°C). The nurse may conclude which of the following regarding this temperature reading? This is a low temperature for a person his age. The reading is likely due to drug or alcohol intake. This is a high temperature for a person his age. This is a normal temperature for a person his age.

This is a high temperature for a person his age

Why does the nurse remove the patient's elastic stockings at least once per shift? To check the skin for irritation or breakdown. To permit the skin to breathe. To air out the stockings and allow sweat to evaporate. To wash the legs with a disposable bath product.

To check with the skin for irritation or breakdown

The nurse assesses the BP in both arms of a newly admitted patient. Why would the nurse do this? To practice the technique of blood pressure measurement. To determine if there is a difference in the readings between the two arms. To verify the BP reading is 10 mm Hg higher in the dominant arm. To assess for a pulse deficit and record this as a baseline measurement.

To determine if there is a difference in the readings between the two arms

The nurse is performing passive shoulder and elbow exercises for a patient who is recovering from surgery to remove a soft-tissue tumor in her upper arm. Why does the nurse cup one hand around the patient's elbow and support the forearm and wrist during the ROM exercises? To keep the arm above the level of the heart To listen for crepitus in the joint To ensure stability while exercising the joint To assess the patient's muscle tension

To ensure stability while exercising the joint

When preparing to apply elastic stockings, why does the nurse assess for skin discoloration? Correct! To identify the potential risk for deep vein thrombosis (DVT) To select the proper stocking size To identify improper patient positioning To determine whether a sequential compression device is needed

To identify the potential risk for Deep Vein Thrombosis (DVT)

The nurse will take the patient's vital signs preoperatively and record them as part of the patient's preparation for surgery. Why is it necessary to take vital signs preoperatively? (Select all that apply.) To provide the patient with reassurance that he or she is being cared for by a competent staff. To provide a set of vital signs to use for comparison during and after surgery. You Answered To ensure the equipment is appropriately calibrated and functional. To verify the patient is not experiencing any complications that may contraindicate surgery or require intervention. You Answered To determine whether the patient is "feeling funny" or &quotdifferent&quot.

To provide a set of vital signs to use for comparison during and after surgery To verify the patient is not experiencing any complications that may contraindicate surgery or require intervention

The NAP reports to the nurse that the patient's pulse oximetry is 88%. What action(s) should the nurse take? (Select all that apply.) Verify the reading by taking the patient's pulse oximetry. Notify the health care provider. Perform a cardiopulmonary assessment. None should be taken because this is a normal value. Assist the patient to a high-Fowler's position. Assist the patient to a fully supine position. Be prepared to administer oxygen.

Verify the reading by taking the patient's pulse oximetry Notify the health care provider Perform a cardiopulmonary assessment Assist the patient to a high-Fowler's position Be prepared to administer oxygen

The nurse has delegated the task of temperature assessment to the NAP. Which information should be provided to the NAP? (Select all that apply.) The type of temperature required. The patient's age. The frequency for taking or monitoring the temperature. The patient's diagnosis. What changes to report immediately to the nurse.

What changes to report immediately to the nurse The frequency for taking or monitoring the temperature The type of temperature required

The nurse is validating the NAP's skill with respiratory rate assessment. Which of the following actions, if made by the NAP, indicates that further instruction is needed? After taking the patient's pulse, the NAP continues to hold the patient's wrist, moving the arm across the patient's chest, and focuses on the patient's breathing. When the patient's respiratory rate is irregular, the NAP counts the patient's respirations for 1 full minute. When a patient inhales a breath, the NAP counts that as one, and when the patient exhales the breath, the NAP counts that as two. When the patient's respiratory rate is less than 12 or greater than 20, the NAP counts the patient's respirations for 1 full minute.

When a patient inhales a breath, the NAP counts that as one, and when the patients exhales a breath, the NAP counts that as two

Which instruction would the nurse give a patient who is able to assist with transfer from a bed to a wheelchair using a transfer belt? Please push down onto the mattress with both hands and stand when I count to three. When I count to three, please rock yourself into a standing position. Please tell me how I can best help you get up off the bed and stand up. Please hold on to my waist while I help you stand.

please push down onto the mattress with both hands and stand when I count to three