Comfort measures
After 30 minutes, the nurse is preparing to remove the cold therapy application when the client asks if it can be left on a little longer. What is the best action by the nurse?
Explain that leaving cold therapy on for longer than 30 minutes can cause tissue necrosis.
While performing client assessment, the nurse notes urine leaking around the indwelling catheter of a male client. The nurse tells the client that the catheter will need to be placed. The client asks why it cannot "just be repositioned." What is the best response by the nurse?
"Repositioning the catheter could cause damage to the urethra or prostate." Rationale: Repositioning the catheter could cause damage to the urethra or prostate and, thus, the catheter should be replaced.
What instruction would the nurse give the client before removing an indwelling urinary catheter?
"Take several slow, deep breaths."
The nurse is caring for a male client who requires insertion of an indwelling urinary catheter. The client is quite anxious about the procedure and asks the nurse what he can do during the procedure to help it go more smoothly. What is the best response by the nurse?
"Taking deep breaths and bearing down during the procedure may make passage of the catheter through the urethra easier."
A client reports a burning sensation when urinating for the first time following the removal of an indwelling urinary catheter. In this situation, what would be the nurse's intervention?
Inform the client that this is normal for the first few voids.
Which question by the nurse, to the client, will best help evaluate the outcome of having applied cold therapy?
"Do you feel your muscle spasms have decreased?"
Which question, used for a pain assessment, would assess a client for the perception of pain?
"Do you find any meaning in your pain?"
The nurse is caring for a 72-year-old male client who requires insertion of an indwelling urinary catheter. What is an important assessment question for the nurse to ask the client prior to the procedure?
"Do you have a history of prostate problems?"
The nurse is presenting an educational inservice about comfort and asks the participants to provide examples of effective comfort measures. Which responses by participants indicate a correct understanding of the concept? Select all that apply.
"Holding a client's hand during an invasive procedure or during times of emotional stress" "Keeping the client's environment free from unpleasant odors" "Administering prescribed analgesic medications" "Assisting a client with hygiene needs" "Straightening wrinkled bed linens"
A nurse is removing a client's surgical sutures. Place the following steps in the correct order. Use all options.
1) Clean the incision using the wound cleanser and gauze. 2) Using the forceps, grasp the knot of the first suture and gently lift the knot up off the skin. 3) Using the scissors, cut one side of the suture below the knot, close to the skin. 4)Grasp the knot with the forceps and pull the cut suture through the skin. 5)Remove every other suture to be sure the wound edges are healed. 6)Apply adhesive closure strips.
A nurse is administering intermittent closed-catheter irrigation to a client. Place the following steps in the correct order. Use all options.
1)Cleanse the access port on the catheter with an antimicrobial swab. 2)Clamp or fold the catheter tubing below the access port. 3)Attach the syringe to the access port on the catheter using a twisting motion. 4)Gently instill solution into the catheter. 5)Remove the syringe from the access port. 6)Unclamp or unfold the tubing and allow the irrigant and urine to flow into the drainage bag.
A nurse is preparing to initiate a continuous closed bladder irrigation for a client. The nurse has completed the preparation steps. The sterile irrigation bag is prepared, labeled, and flushed. The tubing is clamped, and the end cover has been replaced. The nurse has put on gloves and then completes the next steps listed below. Place them in the order that the nurse would perform them. Use all options.
1)Cleanse the irrigation port with an alcohol swab. 2)Aseptically attach irrigation tubing to irrigation port of the three-way catheter. 3)Check to make sure the clamp on the drainage tubing is open. 4)Release the clamp on the irrigation tubing. 5)Regulate the flow at the determined drip rate.
The nurse is assisting a client to use progressive muscle relaxation techniques. Place in order, from first to last, the action the nurse will implement. Use all options.
1)Explain procedure and rationale to client. 2)Assist client to a comfortable position. 3)Ask client to focus on a specific muscle group. 4)Instruct client to tighten that muscle group and hold it tight for 5 seconds. 5)Instruct client to totally relax a specific muscle group and concentrate of the sensation.
Place in order, from first to last, the actions the nurse will perform when planning to remove surgical staples. Use all options.
1)Open the staple removal kit. 2)Position the staple remover under the staple to be removed. 3)Firmly close the staple remover and remove every other staple. 4)Assess wound to see if the edges remain approximated. 5)Remove the remaining staples.
The nurse is preparing to apply an external heating pad. To be effective yet not cause damage to the underlying tissue, what temperature range will the nurse set the pad?
105°F to 109°F (40.5°C to 43°C)
When placing an indwelling urinary catheter, where should the nurse hold the catheter?
2 to 3 in (5 to 7.5 cm) from the tip of the catheter
A nurse gives a 13-year-old client an ice bag to place over a sprained ankle. How long should the nurse have the client apply the bag before the nurse removes it?
20 minutes
A nurse is caring for a client receiving a continuous closed bladder irrigation. The client's urine output prior to initiating the irrigation was 350 mL. After approximately 6 hours, the nurse empties the drainage bag and records an amount of 1,200 mL. The irrigation is running at 100 mL/hour as prescribed. The nurse documents a urine output of which amount?
600 mL Rationale: The total amount of irrigant and urine in the drainage bag is 1200 mL. Based on the information, the client has received 600 mL of irrigant (6 hours at 100 mL/hour). To determine the urine output, the nurse would subtract the amount of irrigant instilled (600 mL) from the total volume of drainage (1,200 mL) to obtain the volume of urine output, which would be 600 mL.
A nurse is providing care to a client who is receiving a continuous closed bladder irrigation. The nurse inspects the solution bag labeled as bladder irrigant and notes that the solution was started this morning at 6:30 am. The nurse would plan to discard this solution and hang new bag of irrigant solution if the current solution was not completely infused by which time?
6:30 am tomorrow Rationale: Sterile bladder irrigant solution not used within 24 hours of opening should be discarded. The start time was 6:30 am this morning, so the current solution bag should be discarded if not completely used by 6:30 tomorrow morning.
The nurse is placing an indwelling urinary catheter for a female client. Once urine drains into the catheter tubing, what should the nurse do next?
Advance the catheter an additional 2 to 3 in (5 to 7.5 cm). Rationale: Advancing the catheter an additional 2 to 3 in (5 to 7.5 cm) ensures placement in the bladder and facilitates balloon inflation without damaging the urethra.
A client tells the nurse that the heartburn she is experiencing is worse when she eats spicy foods. What would the spicy food be considered?
An aggravating factor.
The nurse is performing an irrigation of the client's catheter using a closed system. What should the nurse use to disinfect the aspiration port?
An antimicrobial swab.
The nurse has removed the sutures and is now planning to apply wound closure strips. What should the nurse do before applying the strips?
Apply a skin protectant to the skin around the incision.
What action by the nurse is most appropriate when attempting to remove surgical staples that have dried blood or drainage on them?
Apply moist saline compresses to loosen crusts before attempting to remove the staples.
The nurse prepares for insertion of an indwelling urinary catheter for a female client. Prior to catheter insertion, what should the nurse do? Select all that apply.
Assess the client's degree of physical limitations., Question the client about any allergies to latex or iodine., Confirm the medical prescription for indwelling catheter insertion.
The nurse, assessing a client's pain, asks the client if there are any other factors that consistently relate to the pain. What characteristic of the pain is the nurse assessing with this question?
Associated phenomena.
The nurse is assessing the pain of a neonate with altered respirations. Which pain assessment scale would be the best choice for this client?
CRIES pain scale.
A nurse is administering continuous closed-bladder irrigation to a client. After performing this intervention, the nurse observes that the irrigation solution is not flowing at the prescribed rate. Which actions should the nurse take? Select all that apply.
Check the tubing for kinks or pressure points., Open the clamp all the way., Raise the bag 3 to 6 in (7.5 to 15 cm). Rationale: When the irrigation solution is not flowing at the prescribed rate, the nurse should first make sure the clamp is opened all the way and then check the tubing for kinks or pressure points
The nurse is caring for a female client with an indwelling urinary catheter. The nurse notes that the catheter is not draining. What is the correct action by the nurse?
Check the catheter tubing for kinks or twisting.
A nurse is providing care to a client who is receiving a continuous closed bladder irrigation. The nurse notes that the hourly drainage is less than the amount of the irrigation being given. Which actions by the nurse would be most appropriate? Select all that apply.
Check the tubing for any kinking Palpate the client's bladder for distention
The nurse is irrigating a client's urinary catheter using a closed system. What action would the nurse perform after cleansing the access port on the catheter?
Clamp or fold the catheter tubing below the access port.
The nurse receives a prescription to remove an indwelling urinary catheter from a client who is pregnant and on bed rest. The nurse should be sure to maintain which safety protocol when performing this procedure?
Clean technique.
In which client would the application of an external heating pad be contraindicated?
Client who has a wound that is bleeding.
Which clients will the nurse recognize are at an increased risk of thermal injury when using an external heating pad? Select all that apply.
Client who is an older adult. Client who has diabetes. Client who has peripheral neuropathy Client who has a spinal cord injury.
The nurse is implementing environmental changes to promote a client's comfort and pain management. Which is an example of this type of intervention?
Closing the client's room door to reduce unnecessary noises
The nurse is caring for a female client with an indwelling urinary catheter. The client reports sudden pain and urethral spasm. What is the best action by the nurse?
Deflate the balloon, remove the catheter, and replace.
The nurse is assessing a cancer client's pain. The client is unable to point to a specific area of pain; rather, the client moves a hand over the abdomen to indicate the pain. What type of pain is this client experiencing?
Diffuse
The nurse is performing frequent skin assessment at the site where cold therapy has been in place. The nurse notes pallor at the site and the client reports "it feels numb." What is the best action by the nurse at this time?
Discontinue the therapy and assess the client.
What should the nurse do with any surgical staples removed from a surgical incision?
Dispose of them in a sharps container.
The nurse meets resistance when inserting a Foley catheter into a client. What would be the recommended action in this situation?
Do not force the catheter. Rationale: If resistance is met when inserting a Foley catheter, the nurse should not force the catheter as this could cause trauma to the structures. The nurse could rotate the catheter ½ turn and try to advance it again. If this does not work, the nurse should notify the health care provider.
The nurse, assessing a client for pain, looks for behavioral responses to the pain. Which is an example of a behavioral response?
Grimacing
When removing an indwelling urinary catheter from a client, the nurse prepares to deflate the catheter balloon. Which is the proper method for deflating the balloon?
Insert a syringe into the balloon inflation port and allow the water to come back by gravity.
When assessing a client's pain, what characteristic of pain does the nurse assess using a pain rating scale?
Intensity
A client with an indwelling urinary catheter has a PRN prescription for intermittent catheter irrigation. The nurse notices there is no urine coming out of the catheter and that the client is complaining of bladder pain and pressure. What might the nurse do to rectify this situation?
Irrigate the catheter with normal saline to restore patency.
The nurse is teaching a client the purpose of using an external heating pad. What should the nurse include in the teaching plan? Select all that apply.
It promotes healing by accelerating the body's natural inflammatory response. It reduces the discomfort of muscle tension and muscle spasms It helps to relieve pain from arthritis and joint stiffness. It can be used to treat inflammation, chronic pain, and surgical wounds.
When applying an external heating pad, which prescription from the health care provider would the nurse question?
Leave heating pad on for 40 to 45 minutes, then off for 2 hours.
The nurse is attempting to insert a urinary catheter into a female client's bladder and realizes the catheter has been inserted into the vagina. Which action is most appropriate?
Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter.
The nurse is inserting an indwelling urinary catheter for a female client. The nurse notes that no urine flow is obtained and that the catheter appears to be in the vaginal orifice. What is the next step by the nurse?
Leave the misplaced catheter in place as a marker and repeat the procedure with a new catheter.
Place in order, from first to last, the actions the nurse will perform when applying a warmed moist compress. Use all options.
Leaving it on for more than 30 minutes can cause complications such as tissue injury.
A client rates pain on a numeric pain scale at a "5" out of 10. What type of pain is this client experiencing?
Moderate
When assessing a client, the nurse may identify which physiologic response to pain?
Muscle tension and rigidity.
The nurse is inserting an indwelling urinary catheter for a female client. Despite several tries, the nurse cannot get the catheter to advance into the bladder. What is the next action by the nurse?
Notify the client's health care provider
When assessing a wound 2 hours after removing the surgical staples, the nurse notes that the wound edges have begun to pull apart. What action should the nurse take next?
Notify the health care provider that the wound edges are coming apart.
The nurse is positioning a client for the removal of an indwelling urinary catheter. Where should the nurse stand during the procedure?
On the client's left side, if left handed.
The nurse irrigates an indwelling urinary catheter through a closed system. Why is this preferable to opening the catheter?
Opening the catheter can lead to contamination and infection.
What are important elements for the nurse to remember regarding proper attachment of an indwelling urinary catheter for a male client? Select all that apply.
Place drainage bag below the level of the bladder., Leave slack in catheter to ensure ease in client leg movement., Secure catheter tubing to the client's inner thigh or lower abdomen.
The nurse is caring for a female client with an indwelling urinary catheter. Upon entering the room, the nurse notices that the client has placed the catheter bag next to her in bed. The client's bladder is distended, and she reports of bladder pain. What is the correct action by the nurse?
Place the catheter bag lower than the client and assess for the flow of urine.
The nurse is assessing a client's pain and asks the client, "What words would you use to describe your pain?" What characteristic of pain is the nurse assessing with this question?
Quality
When removing an indwelling urinary catheter from a client, the nurse notices resistance while attempting to pull out the catheter. What would be the immediate intervention in this situation?
Reattach the syringe to the port, aspirate again, and reattempt catheter removal.
The nurse is explaining the benefits of cold therapy to a client. What should the nurse include in the teaching plan? Select all that apply.
Reduces swelling and inflammation Slows the transmission of pain stimuli Reduces bleeding and hematoma formation
What action will the nurse take to ensure a wound is ready for the sutures to be removed?
Remove every other suture and assess the wound edges. To ensure the wound is ready for the sutures to be removed, the nurse should only remove every other suture and then assess the wound to ensure the wound edges are healed and the wound remains approximated.
A nurse is caring for a female client with an indwelling urinary catheter. While performing client assessment, the nurse notes urine leaking around the catheter. What is the correct response by the nurse?
Remove the current catheter and reinsert a new one.
The nurse is inserting an indwelling urinary catheter for an uncircumcised male client. After the catheter has been anchored properly, what is an important step for the nurse?
Replace the foreskin into its non-retracted position. Rationale: The foreskin will need to be replaced into its natural position. Leaving it retracted could increase swelling and stricture, making it painful for the client. Therefore, the foreskin should not stay retracted.
When assessing the area of application of a warm compress, the nurse observes skin maceration of the surrounding area, and the client reports increased discomfort. What should the nurse do first?
Skin color Presence of sensation Distal pulses Evidence of edema
A nurse is performing a catheterization of a male client. The nurse meets resistance when advancing the catheter. What should the nurse try before stopping the procedure and notifying the health care provider?
Stop for a moment and have the client take several slow, deep breaths. Rationale: By stopping for a moment and having the client take several slow, deep breaths the urethra may relax, making advancing easier.
When applying a warm compress, which client will benefit most from the application of moist heat instead of dry heat? A client who:
Stop the heat application and completely remove the compress.
The nurse is inserting an indwelling urinary catheter for a female client. The client moves her leg accidently, contaminating supplies. What is the correct action by the nurse?
Stop the procedure, obtain new supplies, and restart procedure.
During sitz bath therapy, a client reports feeling dizzy and lightheaded. What is the most likely rationale for this occasional effect from sitz bath therapy?
The warm water caused vasodilatation.
The nurse is educating the client about the benefits of implementing nonpharmacological methods of comfort and pain management. What will the nurse include in the teaching plan? Select all that apply.
They can help promote restful sleep., They can lessen the emotional aspects of pain., They can improve client's sense of control., They can strengthen client's coping abilities.
A nurse has just removed an indwelling catheter from a client. Which common complications of urinary function should the nurse monitor for in the client, after removal of an indwelling catheter? Select all that apply.
Urinary retention Difficulty voiding Burning or irritation while voiding
Which action by the nurse is most appropriate when the sutures are difficult to remove because of crusted dried blood?
Use a sterile gauze and sterile saline to gently remove the crusted dried blood.
A nurse is explaining to a caregiver the value of nonpharmacologic methods of pain management. Which statement best describes the proper rationale for using nonpharmacologic methods to help manage pain?
Use of nonpharmacologic methods can diminish the emotional component of pain.
The nurse is inserting an indwelling urinary catheter for a male client. How should the nurse properly cleanse the area prior to catheter insertion?
Using a circular motion, move from the meatus down the glans of the penis.
Prior to indwelling urinary catheter insertion for a female client, how should the nurse cleanse the perineal area?
Wipe from above urinary orifice downward toward sacrum.
The nurse is caring for a male client with an indwelling urinary catheter. Where does the nurse correctly place the bag of the catheter?
attached to the bed itself lower than the client
The nurse is caring for a client with an indwelling urinary catheter. For this client, the nurse plays a key role in prevention of which most common complication?
catheter-associated urinary tract infections
Which client will the nurse expect to be prescribed sitz baths? Select all that apply.
client who had rectal surgery client who had surgery to the perineum client after childbirth
What should the nurse assess before application of sitz bath therapy? Select all that apply.
client's perineal/rectal area client's ability to sit for 15 to 20 minutes client's ability to ambulate to the bathroom client's need to void
Which client is most likely to require that the sutures be left in place for an extended period of time? A client who:
has a current history of alcoholism. Rationale: The client which is most likely to require longer for the wound to heal and therefore the sutures be left in place for an extended period of time is the client with a current history of alcoholism. Excessive alcohol intake alters the absorption of nutrients by the body
When evaluating the effectiveness of sitz bath therapy, what outcome will the nurse expect?
increased comfort of client
The nurse is assisting a client with a sitz bath. Which actions should the nurse perform? Select all that apply.
insert tubing into the infusion port of the sitz bath. Slowly unclamp the tubing and allow the sitz bath to fill Ensure that the call bell is within reach Fill the bowl of the sitz bath about halfway full with tepid to warm water.
The nurse prepares for insertion of an indwelling urinary catheter for a male client. The nurse is right-handed. Where should the nurse stand to perform the procedure?
on the client's right side
What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples?
to splint the area when engaging in activity Rationale:To support the underlying tissues and decrease discomfort, the nurse should teach the client to splint the area when engaging in activities such as changing positions, coughing, or ambulating.
The nurse is inserting an indwelling urinary catheter for an uncircumcised male client. Prior to filling the catheter balloon, how far should the nurse insert the catheter?
to the catheter bifurcation Rationale: The male urethra is about 20 cm long. By inserting the catheter all the way to the catheter bifurcation, this minimizes the risk of inadvertently inflating the balloon while it is still in the urethra.
