Fundamentals 2

A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider?

A halo of erythema on the surrounding skin- might indicate an underlying infection. Also report purulent drainage, swelling, warmth, or a strong odor. Tenderness when touched, pink, shiny tissue with a granular appearance, and serosanguineous drainage are expected. Pinky, shiny tissue with a grainy appearaance is granulation tissue and indicates the proliferative stage of wound healing. Serosanguineous drainage, made up of RBCs ad plasma, is an expected finding in a posteroperative wound healing by secondary intention.

A nurse is assisting a client who is eating at mealtime. The client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first?

Determine whether the client is able to breathe

A nurse is replacing the surgical dressings on a client who had abdominal surgery. Which of the following actions should the nurse take?

Don clean gloves to remove the old dressing- The nurse should use standard precautions by applying clean gloves whenever there is a possibility of coming into contact with secretions. Removing a soiled dressing is a procedure that requires wearing clean, not sterile, gloves. Sterile gloves are not necessary until the nurse applies the new sterile dressing.

A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first?

Explain the procedure to the client. Providing the client with a glass of water, assisting the client into a sitting a position, and measuring the length of the tubing to be inserted is next.

A nurse is changing the bed linens for a client who is on bed rest. Which of the following actions should the nurse plan to take.

Hold the linens away from the body and clothing

A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take?

Insert the tip of the tubing 8cm. The nurse should insert the tip of the tubing 7 to 10 cm (3-4in) along the rectal wall to prevent dislodging of the tube during the procedure and injury to the rectal mucosa. The nurse should hold the enema container a max of 45 cm (18in) above the rectum to prevent painful distension of the colon. The nurse should position the client on the left side in the Sims' position to allow the solution to flow downward into the sigmoid colon and rectum and promote retention of the enema. The nurse should lubricate 5 to 8 cam (2-3in) of the tip of the rectal tube before inserting to decrease the risk of irritation to injury of the mucosa.

A nurse is changing the dressings for a client who is 3 days post op following a cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as which of the following types of drainage?

Purulent drainage- usually indicates wound sloughing or infection Sangunienous is bloody, serosanguineous is blood-tinged pale yellow to watery drainage, and serious exudate is watery drainage

A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. Which of the following actions should the nurse take first?

Start chest compressions- risk priority setting framework. The nurse should perform cardiopulmonary resuscitation, which starts with chest compression, then opening the airway, and breathing for adults and pediatric clients because evidence indicates there is a greater survival rate when chest compressions are started before a breath is initiated.

A nurse is applying antiembolitic stockings for a client who has a history of DVT. Which of the following actions should the nurse take when applying the stockings?

Turn the stocking inside out up to the heel before applying- The nurse should turn the stocking inside out up to the client's heel to make the application of the stocking easier and cause less constrictive wrinkles. The nurse should slide the top of the stocking up over the client's calf all at once to lessen constrictive wrinkles that can decrease venous return. The nurse should remove the stockings once every shift to inspect the skin and check circulation. The nurse should apply another size stocking if the stocking is too long. Rolling the stocking partially down can decrease venous return and cause skin irritation.

A nurse is caring for a client who has major fecal incontinence and reports irritation in the perineal area. Which of the following actions should the nurse take first?

Check the client's perineum (priority-setting framework). The nurse should then apply a fecal collection system, cleanse and dry the area, and apply a barrier cream.

A nurse is caring for a client who is post op following a vaginal hysterectomy and asks for a drink. Her post op diet prescription reads: clear liquids; advance diet as tolerated. Which of the following responses should the nurse make?

"I am going to listen to your abdomen." A common reason clients experience nausea and vomiting after surgery is delayed gastric emptying time or decreased peristalsis. The nurse should auscultate the client's abdomen to determine the presence of bowel sounds before clear liquids can be administered. When a client is ready to resume a post-surgical diet, it is preferable to offer a choice of clear liquids, rather than water. Water provides hydration, but no other nutrients.

A nurse is caring for a client who had a masectomy and has a self-suction drainage evacuator in place. Which of the following actions should the nurse to take to ensure proper operation of the device?

Collapse the device of air after emptying- the nurse should collapse the device after emptying the contents periodically to create enough suction to pull fluid exudate into the collection area of the device. The nurse should keep the diaphragm of the device compressed to maintain suction and prevent clotting of sanguineous drainage. This drainage system is not made for irrigating. The nurse should maintaining the drainage tubing below the level of the incision to enhance drainage, and the nurse should cleanse the drain opening with an alcohol wipe after opening it to decrease entry of microorganisms.

A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take?

Elevate the client's head of the bed to 45 degrees to prevent aspiration. The nurse should flush the tubing with at least 30 ml of water after the enteral feeding to maintain patency of the feeding tube. The nurse should ensure the formula is at room temp before administering because cold formula might cause the client to have intestinal cramping and discomfort. The nurse should auscultate for bowel sounds before each feeding to ensure the client has peristalsis bowel activity for the digestive system to digest or absorb the enteral nutrition.

A nurse is caring for a client who has a haring impairment. Which of the following interventions should the nurse use when speaking with the client?

Face the client when speaking. he nurse should speak toward the client's best or normal ear and move closer to the better ear. The nurse should accentuate the words, especially the consonants, so the info does not sound like mumbling. The client's ability to read lips is inhibited when using exaggerated lip movements. The nurse who speaks loudly or shouts can cause distortion of the sounds because loud sounds are at a higher pitch.

A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nruse take when collecting the specimen?

Place the stool specimen collection container in a biohazard bag. The nurse should have the client defecate into a bedpan or a container for stool collection. The toilet water can dilute and contaminate the liquid specimen. The nurse should place the stool specimen in a clean container using a tongue depressor. The nurse should send the collected stool specimen immediately to the laboratory after labeling the specimen properly to prevent contamination with microorganisms and prevent the specimen from getting cold.

A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care?

Renew the prescription for the use of restraints within 24 hours. The nurse should secure the client's restraints with the softer side next to the client's skin, with the buckle or velco closure on the outside. The nurse should remove the restraint for at least 2 hrs and at that time check the client's skin, change the client position, toilet, or exercise the client. The nurse should ensure 2 fingers can be inserted under the restraints to prevent the restraint from being too loose. If the nurse is unable to insert 2 fingers under the restraint, it could cause impaired circulation to the extremities.

A nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase the client's diet?

Vitamin C and Zinc help fight wound infection. The client should receive a multivitamin, and a mineral supplement of both. In addition, Vitamin E supplements also are needed to aid in skin and wound healing. Vitamin D is importation when used with calcium to prevent osteoporosis. Vitamin K and Iron is important for normal clotting of blood and for impaired intestinal synthesis caused from antibiotics. Calcium is administered to prevent osteoporosis.

A nurse is performing a straight urinary catheterization for a female client who has urinary retention. Which of the following actions indicates the nurse is maintaining sterile technique?

Wipes the labia minora in an anteroposterior direction- with separate cotton swabs to destroy any microorganisms in the area that would contaminate the catheter. The nurse should apply sterile gloves after opening the catheter package to maintain aseptic technique, because the outside of the package is not considered sterile. The nurse should use the nondominat hand to spread the labia and provide the optimal view of the urethral meatus. The non-dominant hand is considered contaminated once the hand touches the client's skin. The nurse should use a separate cotton ball to wipe the right and left labia majora to destroy any microorganisms on the skin surface that would contaminate the catheter.

A nurse is assessing a client who has an onset of severe back pain of an unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client?

"What do you think caused the onset of your pain?"- The nurse is using an open-ended question that allows the client to respond with a wide range of info by using more than one or two words.

A nurse is collecting a urine specimen for culture and sensitivity for a client who has a UTI. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take?

Clamp the tubing below the collection port- the nurse should clamp the tubing below the collection port to allow fresh uncontaminated urine to collect before withdrawing the specimen through the port and placing it in a sterile specimen cup. The nurse should cleanse the collection port with an antimicrobial swab to prevent contamination, place the specimen cup to prevent contamination, and use a fresh specimen obtained near the indwelling urinary catheter to prevent contamination.

A nurse is providing teaching to a client who has a new colostomy about proper care. Which of the following information should the nurse include in the teaching?

Cleanse the skin around the stoma with warm water- the nurse should instruct the client to cleanse the skin around the stoma with warm water, because using soap can leave a residue on the skin an cause poor adherence of the pouch adhesive. The nurse should instruct the client to change the pouch every 3-7 days to avoid skin breakdown around the stoma. The nurse should instruct the client to not place an aspirin in the ostomy pouch to decrease odor, because it can cause stoma bleeding. The nurse should instruct the patient to change the colostomy bag before a meal because drainage from the ostomy is least likely to occur.

A nurse is planning care for a client who has a prescription for collection of a sputum specimen for culture and sensitivity. Which of the following actions should the nurse take when obtaining the specimen?

Collect the sputum upon arising in the morning. The nurse should encourage the client to force fluids, especially clear fluids, to help to thin respiratory secretions. However, evening hours are not the preferred time for obtaining a deep sputum specimen. The nurse should collect the sputum specimen ordered for culture and sensitivity before the client receives antibiotic therapy to prevent interference with the laboratory results. The nurse should collect 4 to 10 ml of sputum before sending the specimen to the laboratory to provide an adequate amount of sputum to test for culture and sensitivity.

A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following information should the nurse include in the teaching?

Hold breath for 5 seconds after goal volume is reached. The nurse should instruct the client to inhale slowly to reach goal volume and to decrease collapse of alveoli in the client's lungs. The nurse should instruct the client to breathe normally for short periods of time between each cycle of breaths, to reduce hyperventilation and fatigue. The nurse should instruct the client to repeat the patterns for 10 to 20 breaths every hour while awake, which helps to prevent the risk of atelectasis and pneumonia.

A nurse is prepaing to anchor with tape the catheter tube for a male client who has a newly inserted indwelling urinary catheter. At which of the following locations should the nurse tape the catheter?

Lower abdomen- The nurse should secure with tape the client's indwelling urinary catheter to the lower abdomen or the upper aspect of the thigh to eliminate the penoscrotal angle and prevent tissue injury. Do not tape to mid-abdominal, lateral, or medial thigh because they can cause discomfort due to pressure on the urethra at the penoscrotal junction and can lead to tissue injury.

A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take?

Pinch the NG tube while removing the tube. The nurse should pinch the NG tube while removing the tube to decrease the risk of aspiration of any gastric contents. The nurse should instruct the client to take a deep breath and to hold it during the removal of the NG tube to close off the glottis and decrease the risk of aspiration of any gastric contents. The nurse should instill 50 ml of air into the tube to clear the contents of the gastric drainage and decrease the risk of aspiration on removal of the tube. The nurse should disconnect the NG tube from the suction apparatus before removal to decrease injury to the gastrointestinal mucosa.

A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take?

Pull suction catheter back 1cm (0.5in) when the client starts to cough, or resistance is met. This will remove the catheter from the mucosal wall of the trachea prior to suctioning. The nurse should allow at least 1 min between suctioning passes to prevent hypoxia and to hyperventilate the client. The nurse should hyperventilate the client with 100 percent oxygen for at least 2 min before suctioning to decrease hypoxia. The nurse should perform a maximum of 3 passes with the suction catheter because suctioning can cause hypoxia and induce dysrhythmia.

A nurse is preparing to administer eye drops to a a client following surgery. Which of the following actions should the nurse take when instilling the eye drops?

The nurse should drop the eye medication in the outer third of the lower conjunctival sac. The nurse should apply gentle pressure to the nasolacrimal duct after instilling the eye medication for 30 to 60 seconds to keep the meds from running down the duct or out of the eye. The nurse should hold the eye dropper 1 to 2 cm from the lower conjunctival sac to protect the cornea of the eye by preventing the tip of the dropper touching the eye. The nurse should instruct the client to close eyes gently when applying ointment or liquid to distribute the meds and to avoid expelling the meds or injuring the eye.

A nurse is planning care for an adult who has fluid volume excess. Which of the following interventions should the nurse plan to include to monitor the client's weight?

The nurse should weigh the client on arising each day, after voiding, before breakfast. An accurate weight requires the patient to be weighed wearing the same garments, and on the same carefully calibrated scale (balanced to zero before each use). Accurate daily weights provide the easiest measurement of volume status. An increase of 1 kg (2.2lb) is equal to 1,000 ml of retained fluid.

A nurse is planning to administer pain medication to a client who has pain following abdominal surgery .Which of the following actions should the nurse take first?

Use the pain scale to determine the client's pain level. Maslow's hierarchy of needs. Followed by using the pain scale to determine the client's pain level, the nurse should check the client's allergies, obtain the client's vital signs, and discuss the adverse effects of pain medication with the client.

A nurse is caring for a toddler at a well-child visit when the mother calls to the nurse, "Help! My baby is choking on his food." Which of the following findings indicates the toddler has an airway obstruction?

Inability of the toddler to cry or speak. When the client has no sound passing through the vocal cords, the nurse should identify a complete airway obstruction is evident. The nurse should use the Heimlich maneuver to dislodge whatever is obstructing the trachea. The expected timing for capillary refill time or blanch testing of the nail bed is less than 2 seconds. Delayed capillary refill time can indicate circulatory impairment, not an airway obstruction. The presence of mild emesis and flushing does not indicate an airway obstruction, and cyanosis is associated with poor oxygenation (which indicates an airway obstruction)

A nurse is preparing to assist with ambulation of an older adult client who was on bed rest for 3 days. Which of the following actions should teh nurse take to decrease the risk of fall?

Use a gait belt during ambulation- to keep the client's center of gravity midline and decrease the risk of fall. The nurse should ensure the client is wearing nonskid shoes or slippers when ambulating to decrease the risk of fall from slipping. The nurse should encourage the client to dangle his legs on the edge of the bed for 60 seconds before attempting to ambulate to decrease the risk of fall caused by orthostatic hypotension. The nurse should walk beside the client to provide physical support ambulating and decrease the risk of fall.

A nurse is preparing to administer an IM injection to a client who is overweight. Which of the following sites should the nurse use for the injection?

The side hip between the iliac crest and anterior iliac spine- forms the ventrogluteal injection. This site is preferred site for IM injections for an adult client. The nurse should prepare for injection by placing a hand on the client's greater trochanter (right hand on left hip, for example) with the first two fingers, touching the iliac crest and anterior superior iliac spine, forming a "V" shape. To administer IM meds using the dorsogluteal site, the nurse should select the upper, lateral quadrant of the buttock. However, the nurse should recognized this site can increase risk of injury to the client because the med is more likely to be injected into subcu tissue, and there is increased risk of piercing the sciatic nerve. The nurse should select the outer, posterior tissue of the upper arm when preparing to administer a subcu injection. For IM injection of less than 1ml, the nurse may select the deltoid muscle by placing four fingers on the deltoid muscle with the top finger on the acromion process. The injection site then is three finger widths below the acromion, or about 5cm (2in). To administer IM meds using the vastus lateralis site, the nurse should select the middle portion of the muscle from the midline of the thigh to the midline of the outer side of the thigh. The nurse can place one hand below the greater trochanter and the other hand above the knee to locate middle portion of the muscle for the injection site.

A nurse is caring for a client who is post-op and who has an indwelling urinary catheter to gravity drainage. The nurse notes no urine output for the past two hours. Which of the following actions should the nurse take first?

Check to determine if the catheter tubing is kinked. Priority-setting framework! The first action the nurse should take is to inspect the tubing carefully, straightening out any kinks, and make certain that there are no dependent loops. A common reason a tube is not draining is that there is a kink in the tubing or that the client is lying on it. The nurse should palpate the bladder or perform a bladder scan to determine if the bladder contains urine and the amount of urine. The nurse should obtain a prescription to irrigate the catheter to determine if the absent urine output is due to an obstruction from blood clots or sloughing of bladder tissue. The nurse can encourage the client to drink more fluids or obtain a prescription to increase the IV rate if fluid overload is not a problem for the client to help increase kidney profusion and filtration of urine.

A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following information should the nurse include in the teaching?

Granulation tissue fills the wound during healing- The nurse should include in the teaching that a beefy, red tissue called granulation tissue fills the wound during healing. The wound is left open to drain and heal by secondary intention that should occur within 5 to 21 days. Open wounds place the client at an increased risk for wound infection. A skin graft is placed over the wound bed- Tertiary intention can include the provider placing grafted skin over the client's wound bed after a wound is left open to drain and start healing. Skin grafting is required for deeper wounds, such as full-thickness burns, and is only rarely required for surgical wounds to heal. The wound is closed at a later date- Tertiary intention includes using sutures to close an open wound at a later date after the wound drains and starts to heal. The wound edges are well-approximated- Primary intention occurs when the closing of the wound using sutures or staples occurs at the time the incision is made and the suture line edges become well-approximated during healing

A nurse is planning care for a group of client's who are receiving oxygen therapy. Which of the following client's should the nurse plan to see first?

A client who has heart failure and is receiving 100 percent oxygen via a partial rebreather mask. Priority-setting framework. The nurse should frequently check the bag on a rebreather mask to ensure it inflates properly. If the bag is deflated, the client will rebreathe his own exhaled carbon dioxide instead of receiving the prescribed oxygen dose. Therefore, the nurse should first see the client who has heart failure and is receiving 100 percent oxygen via a partial rebreather mask. Oxygen is a gas which can cause toxicity and is highly combustible, and higher concentrations of oxygen increase the risk of client injury. "A client who has emphysema and is receiving oxygen at 3L/min via a transtracheal oxygen cannula": Routine treatment for chronic lung conditions can include use of transtracheal oxygen cannula. The client will learn to use the device on his own, and the system can provide adequate oxygenation with a low flow rate of oxygen. Three liters per minute of oxygen is the equivalent of 32 percent oxygen delivery. " A client who has an old tracheostomy and is receiving 40 percent humidified oxygen via tracheostomy collar": Routine treatment who has an old tracheostomy includes administration of humidified oxygen or air via tracheostomy collar. The nurse should use humidification to promote loosening of respiratory secretions and prevent cannula obstruction. Forty percent oxygen is the equivalent of administering oxygen at 6L/min. "A client who has COPD and is receiving oxygen at 2 /min via nasal cannula": Routine treatment for a client who has COPD is to administer low dose therapy. Clients who have COPD depend on a low oxygen level to drive their respiratory rate. Two liters per minute is the equivalent of 28 percent oxygen.

A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take?

Exert pressure on the bony prominences the eyelids open- the nurse should hold the upper lid against the eyebrow and the lower lid against the cheekbone when irrigating the eye. The nurse should hold the irrigator 2.5cm above the eye to prevent the irrigator from touching the eye and to prevent the solution from damaging the eye tissue. The nurse should direct the irrigation solution onto the lower conjunctiva sac to prevent injuring the cornea and having contaminated fluid flow down the nasolacrimal duct. The nurse should direct the irrigation solution from the inner canthus to the outer canthus of the eye to prevent injuring the cornea and having contaminated fluid flow down the nasolacrimal duct.

A nurse is changing the dressing for a client who has two Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to decrease skin irritation?

Montgomery straps- priority-setting framework. Least restrictive devices first- the nurse should plan on using montgomery straps to minimize irritation to the skin near the incisional area. Montgomery straps are adhesive strips applied to the skin on either side of the surgical wound. The adhesive strips have holes for using gauze to tie the dressing securely. When the dressing is changed, the ties are released, the dressing replaced, and the ties secured again without removing the adhesive strips. An abdominal binder can hold the dressings in place and decrease skin irritation while the client rests in bed, however, when the client ambulates, the dressings tend to slide out. Securing the dressings first is the preferred method when applying a binder. Therefore, the nurse should use the least restrictive intervention first. Plastic tape adheres well to skin and can cause skin sensitivity when frequently removed and reapplied. However, the nurse should use a less restrictive intervention first. Hypoallergenic tape is used when a client is sensitive to adhesive material; however, hypoallergenic tape can cause sensitivity when frequently removed and reapplied. The nurse should use a less restrictive intervention first.

A nurse is caring for an older adult client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse taken when assisting the client at mealtime?

Offer the client tart or sour foods first- the client who has impaired pharyngeal swallowing should consume tart and sour foods at the beginning of the meal to stimulate saliva production, which helps chewing and swallowing. The client who has impaired pharyngeal swallowing should tilt the head forward to promote swallowing and should minimize distractions at mealtimes to concentrate on chewing thoroughly and swallowing. The client who has impaired pharyngeal swallowing is at risk for choking when liquids (especially thin liquids) are offered while eating solid foods. It is preferable to suggest "dry swallows" to clear the mouth between bites of food.

A nurse is helping a client change his hospital gown. The client has an IV infusion on an infusion pump. Which of the following actions should the nurse take first?

Remove the sleeve of the gown from the arm without the IV line. According to EBP, the nurse should first remove the gown from the client's arm without the IV line. Beginning this process will enable the nurse to move the gown fully off the client and last stop the system to remove the gown off the line, resulting in minimal interruption of the IV flow. The nurse should slow the infusion using the roller clamp to prevent large volume infusion of IV solution while changing the gown. The nurse should disconnect the IV line from the pump while removing and reapplying the gown quickly to maintain the infusion rate prescribed with the pump. The nurse should bring the IV solution and tubing through the outside to the end side of the sleeve of the gown to prevent tangling of the tubing and the gown.

A nurse is caring for a client who is receiving an IV fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site?

Taut skin around the IV catheter site that is cool to the touch. The nurse should stop the IV infusion, elevate the extremity, and apply a warm moist compress, or a cold compress according to the type of infiltration. The client who has a palpable cord felt along the vein may have phlebitis, which is inflammation of the inner layer of a vein. The nurse should discontinue the infusion and start a new IV line in another location. Bleeding at the iV insertion site might indicate the IV system is not intact. The nurse should check to determine if the IV system is intact and if the catheter is within the client's vein. The nurse might need to start a new IV line in another location if the bleeding does not stop after interventions. The client who has redness at the IV catheter entry site might have a local infection. The nurse should remove the IV, clean the site with alcohol, and start a new IV line in another location.