FUNDAMENTALS EXAM 2 EAQ

Which action would the nurse perform to best ensure effective insertion of a venous access device into a patient's arm?

Anchor the vein by placing a thumb 1 to 2 inches below the site.

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?

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

Which statement might the nurse make to nursing assistive personnel (NAP) before delegating the collection of a routine urine sample from a patient with an indwelling urinary catheter?

"Let me know if the urine contains blood or sediment, or appears cloudy."

Which instruction might the nurse give to nursing assistive personnel (NAP) when caring for a patient whose IV access device is to be removed?

"Let me know if you notice any bleeding on the site dressing."

Which statement might the nurse make to nursing assistive personnel (NAP) caring for a patient who has just had an indwelling urinary catheter removed?

"Tell me when and how much the patient first voids."

Why does the nurse need to keep the urine sterile while obtaining a sample from an indwelling urinary catheter?

Sterile technique ensures that microorganisms in the specimen are from the urine, and not the result of contamination.

Which action should the nurse avoid before irrigating a patient's foot wound?

Warm the irrigant to body temperature in the microwave.

Which action will ensure that a sterile urine specimen is handled properly in order to help obtain reliable results?

Having someone take the specimen to the lab immediately

Which of the following technique(s) is/are best for minimizing a patient's risk for injury when inserting a venous access device?

Inserting the needle with the bevel up, Using a vein on the dorsal surface of the arm, Holding the skin taut directly below the site

Which action will best minimize the patient's risk for vein injury when removing an IV access device from a patient's arm?

Keep the hub parallel to the skin.

What is the primary reason the nurse ensures that a patient's indwelling urinary catheter drainage tubing is free of kinks?

Kinks are associated with the development of urinary tract infection (UTI).

Which measurements would the nurse use to calculate the surface area of a patient's pressure injury?

Length & Width

The nurse is delegating to nursing assistive personnel (NAP) the task of assisting with a urinal. The nurse specifies to NAP that the urinal is to be used in bed, not in a standing position, for which patient?

Patient with complete left-sided paralysis caused by a stroke

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?

Perform hand hygiene before donning gloves.

A patient complains of pain during a dressing change. What would be the most effective intervention the nurse could initiate at the next dressing change in order to reduce the patient's pain?

Premedicate the patient with a prescribed analgesic 30 minutes before the intervention.

A dependent, confused patient is being given a bedpan. How can the nurse best ensure the patient's safety?

Raise the side rails on the bed before leaving the room.

The nurse has delegated measurement of a patient's vital signs and catheter care to nursing assistive personnel (NAP). Which observation should the NAP report to the nurse immediately?

Redness noted on the external urethral meatus

When changing a patient's surgical dressing 24 hours postoperatively, when would the nurse apply sterile gloves?

After removing the original dressing materials and performing hand hygiene a second time

When preparing to insert a venous access device, how can the nurse encourage patient compliance with the procedure?

Assess the patient's understanding of the placement of the device.

The nursing assistive personnel (NAP) reports to the nurse that a patient's intravenous access device dressing is wet. What would the nurse do first?

Assess the site.

Which action might the nurse perform to ensure that the wound drainage tubing does not pull on the insertion site?

Attach the tubing to the patient's gown with a safety pin.

Which action will the nurse take to minimize a patient's risk for injury when applying a gauze dressing to an infusion site?

Avoid encircling the arm with tape

When collecting a urine specimen from an indwelling urinary catheter, which action is most likely to ensure that sufficient urine is collected?

Clamping the catheter tubing for 15 minutes before collection

What is the nursing action to set up suction for a Hemovac drainage system?

Compress the hemovac, creating suction.

Which action would maximize the suction produced by the Jackson-Pratt drainage system after the system has been emptied?

Compressing the bulb while replacing the port cap

What might the nurse do to improve a patient's cooperation during the removal of an IV access device?

Describe the entire procedure to the patient.

A male patient on bed rest is permitted to stand to use the urinal. Which action would the nurse take to ensure his safety before helping him to a standing position?

Determine his risk for orthostatic hypotension

After bacteria are cultured from a midstream urine specimen, what is accomplished by sensitivity testing?

Determines which antibiotic agent is most effective in killing the bacteria

The nurse notes that a patient's surgical wound is healing slowly. Which health problem would contribute to slow wound healing?

Diabetes Mellitus

Which instruction would the nurse give to nursing assistive personnel (NAP) to ensure the patient's comfort when a condom catheter is applied?

Use a hair guard before applying the condom catheter.

Which action reduces the nurse's risk for infection when changing the dressing of an infected abdominal wound?

Use appropriate personal protective equipment (PPE).

Which action will the nurse take to minimize a patient's risk for injury when applying a dressing to an infusion site?

Use aseptic technique throughout the process.

Which action would minimize the risk for cross-contamination while cleansing an infected abdominal surgical wound?

Using a new gauze pad for each stroke while cleansing the wound

What would the nurse do to assess a patient's risk for embolus when removing a venous access device?

Visualize the tip of the IV device.

Which instruction might the nurse give to nursing assistive personnel (NAP) regarding the care of a patient with a newly established colostomy?

"Alert me immediately if you see any blood in the fecal matter in the pouch."

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?

"Be sure to maintain aseptic technique."

The nurse is assisting a patient with the placement of a urinal. The patient tells the nurse, "I'll call you when I'm done." What is the nurse's best response?

"Fine. Recap the urinal, hang it on your side rail, and use your call light to let me know you're finished."

Which statement might the nurse make to nursing assistive personnel (NAP) assigned to care for a patient with an established suprapubic catheter?

"I need to know the patient's temperature each time it's taken."

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

The nurse has delegated to nursing assistive personnel (NAP) the skill of assisting with a bedpan for a patient who has had discomfort when walking to the bathroom. Which statement made by the NAP requires the nurse's follow-up?

"If I can get someone to help, I'll walk her to the bathroom."

Which wound would be allowed to heal by secondary intention?

Infected hysterectomy incision

Which instruction might the nurse give to nursing assistive personnel (NAP) regarding the care of a patient with an intravenous access device?

"Let me know when you notice that the IV bag contains less than 100 milliliters."

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?

"Please get the specimen to the lab within 20 minutes."

Which instruction might the nurse give to nursing assistive personnel (NAP) about applying a condom catheter on a patient?

"Read the manufacturer's instructions for applying the adhesive to secure the condom."

Which device is used for wound irrigation?

19-gauge needle attached to a 35-mL syringe

After assisting with a bedpan, the nurse notes that the patient's stool is streaked with bright-red blood. What would the nurse do first?

Ask if the patient has a history of hemorrhoids.

Which action promotes infection control when assisting a patient with a urinal?

Applying gloves before emptying and cleaning the patient's urinal

Which technique is most accurate in identifying an appropriate vein site for IV catheter insertion into the arm?

Apply a tourniquet to the selected arm 4 to 6 inches above the proposed site.

What will the nurse do to prevent possible complications after removing an IV access device in a patient on anticoagulant therapy?

Apply firm pressure to the site with sterile gauze for 10 minutes.

How would the nurse safely apply an enzyme debridement ointment?

Apply ointment to necrotic tissue in the wound while avoiding contact with surrounding skin.

When applying a dressing to an infusion site on a patient's left forearm, what will the nurse do to ensure proper maintenance of the tubing?

Apply the dressing distal to the tubing and catheter hub connector.

Before performing a wound assessment, which nursing action would reduce the patient's risk for infection?

Applying clean gloves

When changing the pouching system, which routine step best minimizes irritation of the skin surrounding the stoma?

Avoiding unnecessary changes of the pouching system

Which action minimizes the patient's risk for injury when inserting a venous access device into the arm?

Checking for a radial pulse once the tourniquet has been applied

Which nursing action minimizes a patient's risk for injury during removal of an indwelling urinary catheter?

Checking the documentation for the volume of fluid used to inflate the balloon

What is the most effective way to prevent infection when providing catheter care for a patient?

Cleanse from the meatus outward.

The nurse is using chlorhexidine to prepare the site before inserting a venous access device into the median cubital vein of a 60-year-old patient. Which action is correct?

Cleanse the area by first swabbing horizontally, then vertically with the applicator for about 30 seconds.

When preparing to apply a condom catheter, the nurse would do what first?

Close the door and draw the bedside curtain

A newly inserted suprapubic catheter becomes dislodged. What action should the nurse perform first?

Cover the site with a sterile dressing.

Which imaging study or diagnostic test would the nurse review to determine if the pressure ulcer on a patient's left heel is infected?

Culture and sensitivity test

A nurse is irrigating a patient's abdominal wound 2 days postoperatively. Which finding would need to be reported to the health care provider?

Drainage that was not present previously

The nurse is assisting with a bedpan for a patient who had knee surgery 24 hours ago. What is the best way for the nurse to maximize comfort while the patient uses the bedpan?

Elevate the head of the bed to between 30 and 60 degrees.

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.

What is the most important action the nurse can take to ensure that a midstream urine specimen does not become contaminated?

Ensure that the patient's perineum has been cleansed before the specimen is obtained.

Which is not an expected outcome on a first voiding after catheter removal?

Fever and back pain

Which measure may be taken to minimize the staff's risk for infection from a urine specimen?

Firmly securing the lid of the urine specimen container

When irrigating a wound, how would the nurse know the right amount of pressure to apply?

Follow the general rule of keeping the pressure between 4 and 15 psi.

What is the nurse's best response when additional bloody drainage appears on the initial abdominal dressing of a patient who had surgery 7 hours ago?

Further assess the patient and the wound.

Which initial nursing action would best help the patient learn self-care of a colostomy pouching system?

Giving the patient a handheld mirror to watch the nurse provide care

The wound bed of a patient's pressure injury is red. What does this finding indicate to the nurse?

Granulation Tissue

Why is it important to label the gauze dressing covering the site of an intravenous access device with the date, time, and nurse's initials?

Informs the nurse and other staff when the next dressing change is due

The nurse is inserting an over-the-needle catheter into a newly admitted patient. What will the nurse do after confirming blood return?

Lower the Catheter until it is flushed with the skin

The nurse is preparing to administer an enema. How can the nurse best facilitate insertion of the rectal tube?

Lubricate the first 6.5 to 7.5 cm (2.5 to 3 inches) of the tip of the tube.

What can the nurse do to help ensure an accurate result when collecting a midstream urine sample for a patient who is menstruating?

Make a note on the lab slip that the patient is menstruating.

A patient with a nasogastric tube, an intravenous infusion line, and an indwelling urinary catheter needs to be placed on the bedpan. Which action would the nurse take first to ensure the patient's safety?

Obtain help to place the patient on the bedpan.

When pouching a patient's colostomy, which action reduces the patient's risk for injury?

Protecting the skin from irritation caused by fecal drainage

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.

What would the nurse do for a patient who is complaining of penile pain 15 minutes after having a condom catheter applied?

Remove the Catheter

Which intervention can the nurse delegate to nursing assistive personnel (NAP) in caring for a patient with a wound?

Reporting the presence of wound odor

Which action can the nurse delegate to nursing assistive personnel (NAP) to help prevent the development of pressure injury in an older adult patient?

Reposition the patient at least every 2 hours.

Which nursing action reduces the risk for injury in a patient with a suprapubic catheter?

Securing the catheter to the abdomen

The nurse is preparing to insert a venous access device into a newly admitted 75-year-old patient. Which vein is not an appropriate choice for IV insertion in this patient?

Superficial dorsal vein

When emptying a Jackson-Pratt drain, which issue should nursing assistive personnel (NAP) report immediately to the nurse as a potential abnormality?

The amount of drainage was greater today than yesterday.

While performing catheter care, the nurse moves her hand, allowing the patient's labia to close around the catheter. Why would the nurse repeat this part of the care?

The labia have contaminated the area.

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.

Why would the nurse assess a patient's abdomen before helping with the use of a urinal?

To assess for bladder distention

Why would the nurse ensure that a patient's condom catheter is not twisted?

To prevent the catheter from coming off

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 reduce the patient's risk for infection

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 tract infection (UTI)

Which practice protects the nurse from infection when changing the dressing on an infected pressure injury?

Use Appropriate PPE

All of the following factors are known to increase the risk of urinary tract infection (UTI) except which one?

Use of plain soap instead of an antiseptic cleanser for perineal hygiene

A patient who had surgery yesterday has the initial dressing covering the surgical site. What is the nurse's responsibility in assessing this patient's wound?

Wait until the health care provider orders the removal of the surgical dressing.

What is the proper method for cleansing the evacuation port of a wound drainage system?

Wipe it with an alcohol sponge.

What is the nurse's initial action when preparing to change a patient's colostomy pouching system?

applying clean gloves

How might the nurse prepare a patient to anticipate some discomfort when inserting a venous access device?

instruct the patient to expect a sharp, quick stick