Evolve qs

2. What is the primary reason the nurse applies sterile gloves rather than clean ones when caring for a patient with a newly inserted suprapubic catheter? To protect the nurse and other patients from pathogens To collect a sterile urine sample To reduce the patient's risk of infection To reduce the patient's risk of injury

C

1. What is the best reason for the nurse to instruct a male patient to take slow, deep breaths during insertion of an indwelling urinary catheter? To increase oxygenation To reduce blood pressure To distract him To promote relaxation

D

1. Which action is part of the preparation for nasotracheal suctioning? Place the patient in a supine position. Preoxygenate the patient with 100% oxygen. Suction 100 mL of warm tap water to flush the suction catheter. Place water-soluble lubricant onto the open sterile catheter package.

D

2. The nurse is preparing to provide perineal care for a female patient who is on bed rest. Which patient position should the nurse use for this care? Supine Prone Side-lying Dorsal recumbent

D

2. 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? Frequently asking the patient how he or she is breathing Ensuring that the oxygen tubing is pulled tight, with little or no slack Securing the oxygen tubing to the patient's clothing to prevent tugging Assessing for proper placement of the mask on the patient's face

D

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

If the oxygen flow rate is 4 L/min or higher, add humidification and verify that water is bubbling in the humidifier.

3. A male patient receiving perineal care tells the nurse "It has started to hurt a little down there." What is the nurse's best response? "When did you start experiencing the pain?" "Rate the pain on a scale of 1 to 10." "I'll assess your perineal area for the possible cause of the pain." "Would you like some pain medication before I continue with your care?"

A

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

A

5. Which action would the nurse take to manage continuous urinary catheter irrigation for a patient whose urine is bright red and contains clots? Increase the irrigation drip rate. Notify the patient's health care provider of the blood and clots in the urine. Encourage the patient to increase fluid intake. Apply ice to the patient's lower abdominal area.

A CORRECT. This is the correct answer. The nurse would increase the irrigation drip rate to flush the urinary tract until the urine was only tinged pink with blood

3. Which statement best illustrates the nurse's understanding of the role of nursing assistive personnel (NAP) when inserting an indwelling urinary catheter in a female patient? "Please direct the light to better illuminate the patient's perineal area." "You need to be comfortable inserting a catheter in a patient of her size." "See if a size 14-French catheter is big enough." "Find out if the patient has any allergies to latex or iodine."

A

5. Which action is most useful in evaluating the effectiveness of oropharyngeal suctioning? Comparing presuctioning and postsuctioning respiratory assessment data Confirming that the patient's pulse oximetry value is >90% Asking the patient to report any symptoms of dyspnea Assessing the patient's skin for signs of cyanosis

A

5. 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 Oxygen flow meter setting Respiratory rate Temperature

B

5. Which is not an expected outcome on a first voiding after catheter removal? Mild burning Fever and back pain Producing only a small amount of urine Discomfort

B

5. Which technique would the nurse use to change a patient's tracheostomy ties? Use a slipknot. Ensure that two fingers fit snugly under the tie. Knot the ends of the tie in the eyelets on the faceplate. Ask the patient to hold his or her breath while the ties are changed.

B

1. Which action would the nurse take to reduce the risk for a catheter-associated urinary tract infection (CAUTI) in a patient with an indwelling urinary catheter? Wear clean gloves when inserting the catheter. Inflate the balloon on the catheter before using it. Use the smallest-size catheter possible. Empty the urine by disconnecting the catheter from the collection bag.

C

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

C

2. When preparing to insert an indwelling urinary catheter in a male patient, it is important for the nurse to do what? Remove the cotton balls from the kit for later use. Advance the catheter 10 to 12 inches or until urine flows. Lubricate the first 5 to 7 inches of the catheter. Hold the penis at a 45-degree angle during insertion.

C

1. A patient with a suprapubic catheter is complaining of pain. What will the nurse do first to help this patient? Ensure that the patient is not lying on the drainage tubing Instruct the patient to increase his or her oral fluid intake Observe the rate of drainage in the urine collection bag Notify the health care provider

A

1. During intermittent open bladder irrigation, a patient complains of pain. Which action would the nurse take first? Examine the drainage tubing for clots, sediment, and kinks. Notify the health care provider. Leave the irrigation drip wide open. Monitor the patient's vital signs.

A

1. How can the nurse best minimize a patient's risk for infection during tracheostomy care? Adhere to sterile technique when appropriate. Frequently assess for signs of local or systemic infection. Monitor for indications that tracheostomy care is needed. Instruct nursing assistive personnel (NAP) to report any changes in color or odor of tracheal drainage.

A

1. Which of the following interventions directly related to patient safety must the nurse consider when providing perineal care to an elderly male patient with a catheter? Wear clean gloves during care. Assess the patient's ability to provide self-care. Encourage the patient to report any pain originating from the catheter. Monitor the amount of urine in the drainage bag to prevent overflow.

A

1. 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 ensure the therapeutic effects of oxygen therapy To prevent any adverse reaction to the prescribed oxygen therapy To minimize the risk of combustion during oxygen delivery

A

2. After oropharyngeal suctioning, what does the nurse do with the supplies? Place the Yankauer catheter in a clean, dry area. Place all disposable equipment into the wrapper of the suction catheter before discarding it in a trash receptacle. Fold the paper drape with the outer surface inward, and dispose of it in a biohazard receptacle. Place dirty gloves in the biohazard receptacle in the patient's room.

A

2. Which action would best minimize a patient's risk for infection during removal of an indwelling urinary catheter? The nurse or nursing assistive personnel (NAP) removing the catheter must employ clean technique. A registered nurse, not NAP, must remove the catheter. Catheter removal must be executed within 10 minutes of beginning the procedure. Catheter removal must take place within 5 days of catheter insertion.

A

2. Which action(s) would minimize the patient's risk for injury during insertion of an indwelling urinary catheter? Assessing the patient for allergies related to latex, antiseptic, tape, and/or iodine-based substances Thoroughly cleansing the patient's perineal area with povidone-iodine solution before inserting the catheter Performing proper hand hygiene and applying gloves before inserting the catheter Terminating the insertion if the patient reports pain at any time during the procedure

A

1. 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.

B

1. Which action would the nurse perform when preparing to suction a patient's oropharynx? Apply sterile gloves. Place the patient in a semi-Fowler's or sitting position. Remove the nasal cannula. Flush the suction catheter with 200 mL of warm tap water.

B

2. Which action would the nurse take to minimize a patient's risk for injury during urinary catheter irrigation? Change the tubing every 8 hours. Use slow, even pressure when injecting the irrigating fluid. Adhere to aseptic technique during the irrigation process. Monitor the patient's temperature every 4 hours.

B

3. As the nurse is preparing to provide perineal care to a female patient with limited mobility, the patient says, "I can do that myself." Which action would be the priority? Provide all the necessary supplies and linen for this task. Assess the patient's ability to perform proper perineal care. Ensure that the patient has privacy while performing perineal care. Document any complaints of irritation or pain in the perineal area.

B

3. When preparing to suction a patient's oral cavity, why would the nurse first suction a small amount of water through the catheter? To moisten the exterior of the plastic catheter To ensure that the catheter's suction is functioning properly To minimize friction as the catheter moves within the oral cavity To avoid startling the patient with the sound created by the suction

B

3. Which intervention reduces the risk for skin breakdown in a patient with a new tracheostomy? Cleaning the stoma with hydrogen peroxide and drying thoroughly Cleaning and assessing the skin around the stoma Assessing temperature and reporting skin breakdown immediately Allowing the patient to re-oxygenate after each tracheal suctioning

B

3. Which observation indicates that instruction given to nursing assistive personnel (NAP) in caring for a patient with an indwelling urinary catheter has been effective? The collection bag has been placed on the side rail of the bed. The excess catheter tubing has been coiled beside the patient's inner thigh. The collection bag has been placed on the bed. The collection bag is held above the level of the bladder while ambulating the patient.

B

3. Which statement might the nurse make to nursing assistive personnel (NAP) assigned to care for a patient with an established suprapubic catheter? "Tell me if the catheter site looks inflamed." "I need to know the patient's temperature each time it's taken." "Wear sterile treatment gloves when you remove the dressing." "Let me know if the patient's catheter is infected"

B

3. Which statement might the nurse make to nursing assistive personnel (NAP) caring for a patient who has just had an indwelling urinary catheter removed? "Teach the patient the signs of a urinary tract infection." "Tell me when and how much the patient first voids." "Explain that voiding might be uncomfortable for 4 to 5 days." "Assess the patient for a distended bladder before the end of the shift."

B

4. As a nasotracheal catheter is inserted to suction the airway, a patient begins to gag and says, "I feel like I'm going to throw up." What is the nurse's best response? Complete the catheter insertion in 5 seconds or less. Remove the catheter. Encourage the patient to take several deep breaths to minimize the nausea. Stop advancing the catheter, and allow the patient to rest for several minutes.

B

4. What is a priority intervention when performing oropharyngeal suctioning for a patient who is receiving oxygen by face mask? Complete the suctioning process in 20 seconds or less. Keep the oxygen mask near the patient's face during the suctioning procedure. Encourage the patient to take several deep breaths before suctioning begins. Increase the oxygen flow rate by 1 L/min for 3 minutes before suctioning.

B

5. How does the nurse evaluate the effect of nasotracheal suctioning on a patient's respiratory status? Asking the patient about symptoms of respiratory difficulty Comparing respiratory assessment data from before and after the suctioning procedure. Confirming that the patient's pulse oximetry value is >90% Auscultating the patient's chest after suctioning

B

5. The nurse is delegating a female patient's perineal care to nursing assistive personnel (NAP). What instruction would the nurse give to ensure the NAP's safety while performing this care? Wear sterile gloves. Wear clean gloves. Wear an isolation gown. Use hot water.

B

What can the nurse do to help ensure an accurate result when collecting a midstream urine sample for a patient who is menstruating? Notify the health care provider. Make a note on the lab slip that the patient is menstruating. Postpone the specimen collection until menses has ceased. Do nothing other than follow normal procedure, since menstruation will not affect the results.

B

What is the most important action the nurse can take to ensure that a midstream urine specimen does not become contaminated? Wear sterile gloves to open the sterile specimen kit. Ensure that the patient's perineum has been cleansed before the specimen is obtained. Determine if the patient has any known allergies. Have the patient rate his or her current pain level.

B

Which nursing action shows the most effective planning for emergency care of a patient with a tracheostomy? Having a spare oxygen mask at the patient's bedside Keeping an obturator and a tracheostomy tube at the patient's bedside Reviewing the agency's policy regarding tracheostomy care Instructing the family to call immediately if the patient has difficulty breathing

B

1. When preparing to discharge a patient who had an indwelling urinary catheter removed 24 hours ago, the nurse would offer patient education regarding which common complication? Urinary incontinence Urinary tract infection Adequate oral hydration Kidney stones

B CORRECT. A urinary tract infection may develop 2 to 3 days after indwelling urinary catheter removal, and the nurse would educate the patient to be alert for signs and symptoms of such an infection.

4. Which statement might the nurse make to nursing assistive personnel (NAP) in order to help ensure reliable results of culture and sensitivity testing of a midstream urine specimen? "I'll need a biohazard bag to put the specimen into." "Please get the specimen to the lab within 20 minutes." "After you replace the cap, please wipe any drops of urine from the outside of the container." "We are out of specimen collection kits."

B CORRECT. The nurse is likely to give this instruction to the NAP, because the specimen must be delivered to the lab within 20 minutes of collection. Doing so ensures that the reliability of the specimen is not compromised.

2. Which response would the nurse report immediately if it occurred in association with nasotracheal suctioning? Patient complains of discomfort during the procedure Patient has a severe bout of nonproductive coughing and complains of sore throat After oxygen delivery device has been reapplied on completion of the procedure, patient's pulse oximetry reading falls to 88% Patient's pulse rate increases by 10 beats/min

C

3. Which instruction might the nurse give to nursing assistive personnel (NAP) helping to care for a patient receiving bladder irrigation? "Tell me how he tolerates the irrigation." "Be sure to check for signs of a urinary tract infection." "Measure and report the patient's temperature to me every 4 hours." "Ask the patient about pain level."

C

3. While suctioning the nasotracheal airway, the nurse notes that a patient's pulse rate has fallen from 102 beats/min to 80 beats/min. What is the best course of action? Encourage the patient to take several deep breaths. Interrupt suction to the catheter for at least 10 seconds. Discontinue suctioning by removing the suction catheter. Assess the patient's pulse oximetry reading to see if oxygenation is adequate.

C

4. How can the nurse promote infection control while providing perineal care for a female patient who has a catheter? By avoiding the application of tension on the catheter By patting, not rubbing, the skin dry after thoroughly rinsing it By cleansing the patient's labia from the pubic area toward the rectum By using warm water to cleanse the patient's entire perineal area

C

4. The nurse has completed the initial inspection of the patient's perineum and is preparing to insert an indwelling urinary catheter. Which action would the nurse complete next? Begin to establish a sterile field. Open and assemble the urine drainage bag. Remove soiled gloves, and perform hand hygiene. Center the drape over the patient's labia.

C

4. When caring for a patient who is receiving supplemental oxygen by face tent, which action ensures that the oxygen is flowing? Testing the closing capacity of the mask's valves 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

C

4. Which action may be delegated to nursing assistive personnel (NAP) regarding the care of a patient with a tracheostomy? Performing tracheostomy care for a patient whose tracheostomy was placed 1 week ago Removing the outer cannula and placing the obturator Holding the tracheostomy tube while the nurse changes the neck ties Monitoring oxygen saturation levels and placing oxygen if needed

C

4. Which action will the nurse implement to reduce the risk of catheter-associated urinary tract infection (CAUTI) in a male patient with an indwelling urinary catheter? Frequently pull on the drainage system tubing. Use the largest-size catheter possible. Clean the urinary meatus daily. Apply antiseptics to the urinary meatus.

C

5. A female patient placed in the dorsal recumbent position for the insertion of an indwelling urinary catheter tells the nurse that she "doesn't feel comfortable in this position" and that her "back really hurts." What is the nurse's best response? Reassure the patient that the procedure will take only a few minutes. Promise to reposition the patient as soon as the catheter has been inserted. Reposition the patient in a side-lying position, with her upper leg flexed at the knee and hip. Explain to the patient that the position will allow the catheter insertion to be more efficient.

C

5. A newly inserted suprapubic catheter becomes dislodged. What action should the nurse perform first? Notify the health care provider Apply pressure over the site Cover the site with a sterile dressing Help the patient into a side-lying position

C

5. 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 can adjust whenever I need to." "I'll alert the nurse immediately if I have any increased difficulty breathing." "I often experience difficulty breathing for no apparent reason, but that is expected."

C

5. While setting up the sterile field in preparation for inserting an indwelling urinary catheter, a male patient is incontinent of urine over most of the supplies. What action would the nurse take to reduce the patient's risk for infection? Rinse off the supplies that were contaminated with urine. Cleanse the patient's urinary meatus. Replace all contaminated supplies, and begin the process again. Change the patient's bed linens.

C

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 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 Instructing the patient to inform staff of any problems with facial dryness or cracking

C

3. 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. Store extra oxygen cylinders horizontally. Place a "No Smoking" sign at the entrance to the house. Keep oxygen 5 feet (about 1.5 meters) away from anything that could generate a spark.

C Keep oxygen at least 10 feet (about 3 meters) away from anything that could generate a spark. Extra cylinders should be stored vertically.

2. The nurse observes the nursing assistive personnel (NAP) providing perineal care to a male patient. Which observation of care requires the nurse's follow-up? Assisting the patient into the supine position in bed Cleansing the tip of the penis with a circular motion, starting at the meatus Reserving the cleansing of the tip of the penis as the final step in perineal care Using a gloved hand to grasp the shaft of the penis in order to retract the foreskin

C Proper cleansing requires that the tip of the penis be cleansed first, to minimize the introduction of pathogens to the meatus. The nurse's observation of improper technique requires follow-up teaching.

Which nursing action reduces the risk of injury in a patient with a suprapubic catheter? Applying sterile gloves before cleaning the catheter insertion site Cleansing the skin surrounding the insertion site Securing the catheter to the abdomen Keeping the drainage bag above the level of the patient's bladder

C Securing the catheter to the abdomen will reduce the risk of injury to the patient by ensuring that excess tension is not applied to the catheter. Such tension could damage the bladder.

1. After bacteria are cultured from a midstream urine specimen, what is accomplished by sensitivity testing? Confirms the accuracy of the results of the culture Identifies the immune system's reaction to the presence of the bacteria Determines whether the patient is allergic to the antibiotic agent with which the provider plans to treat the infection Determines which antibiotic agent is most effective in killing the bacteria

D

3. 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 Assessing breath sounds every shift Securing the tubing snugly to the patient's gown Assessing that the reservoir bag stays inflated

D

3. Which statement might the nurse make to nursing assistive personnel (NAP) assigned to collect a midstream urine specimen from a patient with signs of a urinary tract infection? "Obtain 30 to 60 mL of midstream urine." "The urine has a foul odor." "Teach the patient to collect the urine specimen." "Be sure to maintain aseptic technique."

D

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

D

4. Which action is most important in reducing the risk for infection in a patient receiving open intermittent irrigation of a urinary catheter? Attaching the urinary drainage bag to the bed frame Inspecting the drainage tubing for kinks Disposing of contaminated items after the procedure Cleaning the end of the drainage tubing with an antiseptic wipe before reconnecting it to the catheter

D

4. Which nursing action minimizes a patient's risk for injury during removal of an indwelling urinary catheter? Using a 5-mL syringe to deflate the balloon Using sterile scissors to cut the valve to deflate the balloon Tugging gently on the catheter to pull the balloon through the urethra Checking the documentation for the volume of fluid used to inflate the balloon

D

5. What is the primary reason for performing perineal care on a male patient with incontinence? To provide comfort and a relaxed, refreshed feeling To promote personal hygiene while minimizing perineal odor To remove all microorganisms from the patient's perineal area To reduce the risk of skin breakdown in the patient's genital and perineal area.

D

5. 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? Encourage the patient to take deeper breaths in order to get more oxygen Change the device from nasal cannula to simple face mask Ensure that humidification is present Adjust the float ball on the flow meter to 3 L/min.

D

The nurse has delegated a male patient's perineal care to the nursing assistive personnel (NAP). Which statement made by the NAP requires the nurse's follow-up? "I will check to see if he cleans himself well." "I will let you know if I see any redness or drainage." "I will ask him if he is experiencing any pain in that area" "I will be sure to use hot, soapy water to be sure he's clean."

D

1. The nurse is delegating to nursing assistive personnel (NAP) the perineal care of a female patient who is totally dependent and confined to bed. Which statement by the NAP requires the nurse's follow-up? "I'll ask for assistance if I need help positioning her." "I'll see if she's up to the care right now." "I'll let you know if I notice any signs of redness or discharge." "I'll be sure to use hot, soapy water, since she has been incontinent."

D To minimize skin irritation, warm water and mild soap should be used when cleansing the perineal area, so this statement requires the nurse's follow-up.

2. When preparing the patient's environment for safe oxygen therapy, which intervention is a priority to minimize the patient's risk for injury? Place appropriate signage to alert staff and visitors to the presence of oxygen in the patient's room. Instruct nursing assistive personnel (NAP) to immediately correct or report safety hazards. 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.

c