NUR 2727C Exam #1

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? A. apply a transparent dressing to the insertion site B. use a catheter stabilizing device when applying the dressing C. apply the dressing distal to the tubing and catheter hub connector D. secure the tubing to the patient's dressing with 1-inch tape

C. apply the dressing distal to the tubing and catheter hub connector

Which action would the nurse perform first when preparing to apply sterile gloves? A. perform hand hygiene B. place the package on a stable, flat surface C. assess the glove packaging for wetness or tears D. open the outer packaging

C. assess the glove packaging for wetness or tears

Which assessment finding would the nurse report to the health care provider when giving immediate postoperative care to a client with a newly placed ostomy? A. moderate edema of the stoma B. excessive gas issuing from the stoma C. blanching, dark red to purple color of stoma D. small amount of blood oozing from the stomach

C. blanching, dark red to purple color of stoma

Which action will the nurse implement to reduce the risk of catheter-associated urinary tract infection in a male patient with an indwelling urinary catheter? A. frequently pull on the drainage system tubing B. use the largest-size catheter possible C. clean the urinary meatus daily D. apply antiseptics to the urinary meatus

C. clean the urinary meatus daily

A 2-year-old child is admitted with gastroenteritis and dehydration. Intravenous fluids are prescribed. Which is the most appropriate site for the first intravenous insertion? A. scalp vein near the fontanel B. venous arch on top of the foot C. dorsal metacarpals of the hand D. basilic vein at the antecubital fossa

C. dorsal metacarpals of the hand

Which action would the nurse take next after the nurse immediately stops the infusion of a client demonstrating signs and symptoms of a transfusion reaction? A. obtain blood pressure and pulse B. send a urine specimen to the laboratory C. hang a bag of normal saline with new tubing D. monitor the intake and output every 15 minutes

C. hang a bag of normal saline with new tubing

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? A. reminds the nurse to document the insertion of the device B. proves that the access site was assessed C. informs the nurse and other staff when the next dressing change is due D. reminds the nurse when to change the infusion tubing

C. 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? A. loosen or remove the tourniquet B. advance the catheter 1 inch into the vein C. lower the catheter until it is flush with the skin D. thread the catheter into the vein up to the hub

C. lower the catheter until it is flush with the skin

Which possible legal complication might the nurse face in a situation in which intravenous therapy was administered to the wrong client? A. assault B. battery C. malpractice D. false imprisonment

C. malpractice

Which action by the nurse is best when a client who has a hemoglobin of 6 g/dL is refusing blood because of religious reasons? A. ask the client's family to intervene with the decision B. remind the client that death is a possibility without transfusion C. notify the health care provider of the client's refusal of blood products D. explain that the benefits of blood transfusion may outweigh religious concerns

C. notify the health care provider of the client's refusal of blood products

Which technique is an alternative to restraint use? A. observe the person at least once every 2 hours B. discourage visitors because they can cause confusion C. provide diversions, such as TV, videos, music, and games D. remove clocks and calendars for a person with confusion

C. provide diversions, such as TV, videos, music, and games

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? A. begin to establish a sterile field B. open and assemble the urine drainage bag C. remove soiled gloves, and perform hand hygiene D. center the drape over the patient's labia

C. remove soiled gloves, and perform hand hygiene

Which action would the nurse take if an intravenous insertion site appeared red, warm, and swollen? A. assess for blood return B. discontinue the infusion C. change the existing dressing D. secure the tubing with more tape

B. discontinue the infusion

Which factor would the nurse recognize as the cause when a client's intravenous infusion infiltrates? A. excessive height of the IV bag B. failure to secure the catheter adequately C. contamination during the catheter insertion D. infusion of a chemically irritating medication

B. failure to secure the catheter adequately

Which is not an expected outcome on a first voiding after catheter removal? A. mild burning B. fever and back pain C. producing only a small amount of urine D. discomfort

B. fever and back pain

Which action will ensure that a sterile urine specimen is handled properly in order to help obtain reliable results? A. placing the specimen in a biohazard bag B. having someone take the specimen to the lab immediately C. cleaning the outside surface of the container D. ensuring that a stock of sterile urine collection kits is available

B. having someone take the specimen to the lab immediately

Which wound would be allowed to heal by secondary intention? A. cleft lip repair B. infected hysterectomy incision C. exploratory laparoscopy incision D. facial laceration caused by a pocket knife

B. infected hysterectomy incision

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? A. urinary incontinence B. urinary tract infection C. adequate oral hydration D. kidney stones

B. urinary tract infection

Which statement best illustrates the nurse's understanding of the role of nursing assistive personnel when inserting an indwelling urinary catheter in a female patient? A. please direct the light to better illuminate the patient's perineal area B. you need to be comfortable inserting a catheter in a patient of her size C. see if a size 14-French catheter is big enough D. find out if the patient has any allergies to latex or iodine

A. please direct the light to better illuminate the patient's perineal area

Which of these devices is a restraint alternative? A. roll guards that are attached to the bed frame B. velcro used to hold clothing tight enough to restrict movement C. bed rails that prevent the person from getting out of bed D. a tray table that blocks the person's freedom of movement

A. roll guards that are attached to the bed frame

What is the correct method for applying a condom catheter? A. roll the condom onto the penis, leaving 1 inch between the penis and the end of the catheter B. apply the skin preparation to the glans of the penis and firmly roll on the condom before it dries C. use adhesive or surgical tape to firmly attach the condom to the penis and prevent leakage D. use the adhesive strip provided by the manufacturer. overlap the ends of the strip to secure the condom

A. roll the condom onto the penis, leaving 1 inch between the penis and the end of the catheter

Which action will the nurse take during administration of blood products to ensure the client's safety? A. stay with client during first 15 minutes of infusion B. flush packed red blood cells with 5% dextrose and 0.45% normal saline C. remove the intravenous catheter if a blood transfusion reaction occurs D. administer the red blood cells through a percutaneously inserted central catheter line with a 20-gauge needle

A. stay with client during first 15 minutes of infusion

Which nursing action demonstrates proper procedure in the collection of a wound culture specimen? A. wearing clean gloves to remove soiled dressings B. using a circular motion to cleanse the wound before collecting the specimen C. completing the lab requisition form in a timely manner after collecting the specimen D. sending the specimen to the lab within 30 minutes of collecting it

A. wearing clean gloves to remove soiled dressings

thick layer of dead, dry tissue that covers a pressure injury or thermal burn. it may be allowed to be sloughed off naturally, or it may need to be surgically removed

eschar

protrusion of visceral organs through a surgical wound

evisceration

antibodies against donor white blood cells

febrile nonhemolytic reaction

antibodies against donor plasma proteins

mild allergic reaction

containing, consisting of, or being pus

purulent

bacterial contamination of transfused blood components

sepsis

containing or consisting of both blood and serous fluid

serosanguineous

a mass of dead tissue separating from an ulcer

slough

blood administered faster than circulation can accommodate

transfusion-associated circulatory overload

Which finding by the nurse is the best indicator that measures to prevent postoperative atelectasis after abdominal surgery have been effective? A. vesicular breath sounds heard over both lungs B. client reports no incisional pain with coughing C. client's oral temperature is 98.2 degrees Fahrenheit D. client uses incentive spirometer every 2 hours

A. vesicular breath sounds heard over both lungs

When are sterile non latex gloves recommended for a sterile procedure? A. when there is a possible sensitivity issue B. when the staff member prefers them C. when latex gloves are not conveniently available D. when the patient prefers them

A. when there is a possible sensitivity issue

While preparing a sterile field, the nurse notes that a portion of the sterile drape has come into contact with the patient's gown. Which action is most appropriate in this situation? A. place the sterile supplies only on the portion of the drape that did not touch the gown B. collect the supplies necessary and establish a new sterile field C. determine if the contact occurred within the outer 1-inch perimeter of the drape D. establish the sterile field on the opposite side of the drape

B. collect the supplies necessary and establish a new sterile field

Which genitourinary factor contributes to urinary incontinence in older adult clients and needs to be considered by the nurse when planning the care for these clients? A. sensory deprivation B. urinary tract infection C. frequent use of diuretics D. inaccessibility of a bathroom

B. urinary tract infection

When pouring a sterile liquid into a container on a sterile field, why does the nurse hold the bottle with the label facing the palm of the hand? A. the label is not sterile and will contaminate the field if it is splashed B. the pour spout faces down when the bottle is held with the label facing the palm C. the label may become illegible if it is splashed D. the handgrips on the bottle are molded to fit correctly when the label is facing the palm

C. the label may become illegible if it is splashed

When emptying a Jackson-Pratt drain, which issue should nursing assistive personnel report immediately to the nurse as a potential abnormality? A. the drainage is odorless B. the drainage is straw colored C. the patient doesn't like looking at the drainage tubing D. the amount of drainage was greater today than yesterday

D. the amount of drainage was greater today than yesterday

While checking a blood bag prior to infusion, the nurse notes that the patient's blood type is A+ and the donor's blood type is O+. Which action would the nurse take? A. administer the blood B. return the blood to the blood bank C. notify the physician D. ask the patient if anyone in the family have blood type A+

A. administer the blood

Which action would the nurse perform to best ensure effective insertion of a venous access device into a patient's arm? A. anchor the vein by placing a thumb 1 to 2 inches below the site B. insert the device tip at a 45-degree angle distal to the proposed site C. place the patient's left arm in a dependent position for 5 minutes before assessment D. apply a tourniquet to the left antecubital fossa 8 to 12 inches above the proposed site

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

Which intervention would the nurse do before formulating a teaching plan for a child who is to undergo ostomy surgery? A. assess the child's developmental level B. determine the family's comprehension of the procedure C. provide a list of available community resources to the family D. collaborate with the school in ensuring the child's smooth return

A. assess the child's developmental level

Before using a restraint alternative, what should you do? A. check with the nurse about what type of restraint alternative to use B. ask another nursing assistant to supervise the procedure C. try using various restraints to keep the person from self-injury D. ask the person's doctor to order a restraint, such as a vest

A. check with the nurse about what type of restraint alternative to use

A person has a condom catheter that must be secured with elastic tape. How should you apply the tape? A. in a spiral pattern B. in a chevron pattern C. completely around the penis D. from the condom to the groin

A. in a spiral pattern

A client who had thoracic surgery reports pain at the incision site when coughing and deep breathing. Which action would the nurse take? A. instruct the client to splint the wound with a pillow when coughing B. place the client in the supine position and inspect the site of the incision C. assess the intensity of the pain and administer the prescribed analgesic D. notify the health care provider immediately and then check for wound dehiscence

A. instruct the client to splint the wound with a pillow when coughing

Which action will best minimize the patient's risk for vein injury when removing an IV access device from a patient's arm? A. keep the hub parallel to the skin B. cleanse the site with an antibacterial swab C. cut the dressing to facilitate its removal D. turn the IV tubing roller clamp to the "off" position

A. keep the hub parallel to the skin

Which action would maximize the suction produced by the Jackson-Pratt drainage system after the system has been emptied? A. pinning the tubing to the patient's hospital gown B. compressing the bulb while replacing the port cap C. emptying the drainage container only when it is 90% full D. placing the drainage container below the wound site

B. compressing the bulb while replacing the port cap

Which clinical finding leads the nurse to conclude that an IV has infiltrated rather than caused inflammation? A. pain B. coolness C. localized swelling D. cessation in flow of solution

B. coolness

Which cause would a nurse suspect is responsible for warmth, redness, and tenderness identified at a client's intravenous site? A. rapid fluid delivery B. phlebitis C. allergic response D. infiltration

B. phlebitis

Which action minimizes the patient's risk for injury when inserting a venous access device into the arm? A. wearing clean gloves during the procedure B. using a larger vein found on the palmar (ventral) side of the wrist C. checking for a radial pulse once the tourniquet has been applied D. priming the extension tubing after attaching it to the newly placed venous access device

C. checking for a radial pulse once the tourniquet has been applied

The nurse is preparing to insert a venous access device into a newly admitted 75-year-old patient. Which vein is an inappropriate choice for IV insertion in this patient? A. basilic vein B. cephalic vein C. superficial dorsal vein D. median cubital vein

C. superficial dorsal vein

Which nursing action would be performed first in a client who reports chills and flank pain ten minutes after the initiation of a blood transfusion? A. stop the transfusion B. obtain the vital signs C. notify the health care provider D. maintain the flow with normal saline

A. stop the transfusion

After connecting the condom catheter to the drainage tubing, what should you do with the excess tubing? A. put a clamp on it B. tape it to the person's leg C. coil and secure it on the bed D. cut it off. then use the shorter tubing

C. coil and secure it on the bed

What is the most effective way to prevent infection when providing catheter care for a patient? A. properly dispose of soiled linen B. perform hand hygiene before positioning the patient C. secure the catheter to the patient's leg or abdomen D. cleanse from the meatus outward

D. cleanse from the meatus outward

Why might the nurse offer the patient a bedpan before establishing a sterile field? A. anticipating what the patient might need during a lengthy sterile procedure will minimize patient movement B. a patient's becoming incontinent constitutes a breach in sterile technique C. refocusing the patient's attention on a task decreases anxiety D. assessing the patient's ability to follow instructions will help the nurse maintain the sterile field

A. anticipating what the patient might need during a lengthy sterile procedure will minimize patient movement

The nurse is concerned that a confused patient's erratic movements may compromise the intravenous insertion site. Which action can the nurse take to protect the patient and the site from injury? A. apply an IV site-protection device over the site B. apply restraints to the patient C. check the patient frequently D. instruct the patient to avoid dislodging the IV catheter

A. apply an IV site-protection device over the site

When preparing to insert a venous access device, how can the nurse encourage patient compliance with the procedure? A. assess the patient's understanding of the placement of the device B. insert the access device as quickly as possible C. ask the patient to select the arm preferred for access D. apply a topical anesthetic to the area before inserting the device

A. assess the patient's understanding of the placement of the device

A nurse is irrigating a patient's abdominal wound 2 days postoperatively. Which finding would need to be reported to the health care provider? A. drainage that was not present previously B. redness at the abdominal suture line C. granulation tissue in the wound bed D. the patient reports less pain

A. drainage that was not present previously

Which role would the unlicensed assistive personnel have when caring for a client receiving intravenous therapy? A. monitoring clinical manifestations B. collecting the data to be used in the assessment of the IV site C. administering IV fluids and medications D. evaluating the client for clinical manifestations

A. monitoring clinical manifestations

While preparing supplies on a sterile field, a gauze pad falls off the sterile field. What should the nurse do? A. nothing B. create a new sterile field C. use sterile forceps to move the gauze pad toward the center of the sterile field D. dispose of the gauze before continuing the procedure

A. nothing

How often should a condom catheter be changed? A. once a day after perineal care B. twice a day with morning and bedtime care C. once after each voiding (three or four times a day) D. once a week or less frequently according to agency policy

A. once a day after perineal care

The registered nurse delegates a task to a licensed practical nurse. Which client task can be assigned to the LPN? A. condition: dehydration task: evaluate whether fluid electrolyte needs are being addressed with intravenous therapy B. condition: wound care task: perform sterile dressing changes on acute and chronic wounds C. condition: pain task: notify the primary healthcare provider if client reports pain D. condition: presbycusis task: help with hearing aid replacement

B. condition: wound care task: perform sterile dressing changes on acute and chronic wounds

Which clinical indicators is most commonly used to determine whether the client has a fluid deficit when reporting vomiting and diarrhea for three days? A. presence of dry skin B. loss of body weight C. decrease in blood pressure D. altered general appearance

B. loss of body weight

Which intervention would the nurse implement when providing care for an older adult male client who is immobile and incontinent of urine? A. restrict the client's fluid intake B. regularly offer the client a urinal C. apply incontinence pants D. insert an indwelling urinary catheter

B. regularly offer the client a urinal

Which intervention can the nurse delegate to nursing assistive personnel in caring for a patient with a wound? A. assessing the site for signs of redness or swelling B. reporting the presence of wound odor C. removing a soiled outer dressing D. opening sterile dressings during the dressing change

B. reporting the presence of wound odor

Which instruction might the nurse give to the NAP to help ensure that a wound culture specimen will be transported properly? A. wear sterile gloves when holding the specimen B. take this specimen to the lab immediately C. borrow a specimen collection kit from another unit if we're out of them D. keep the specimen tube horizontal

B. take this specimen to the lab immediately

Which action reduces the nurse's risk for infection when changing the dressing of an infected abdominal wound? A. begin antibiotic therapy before the dressing change. B. use appropriate personal protective equipment C. adhere to sterile technique during the intervention D. complete the dressing change in an effective, timely way

B. use appropriate personal protective equipment

When preparing to insert an indwelling urinary catheter in a male patient, it is important for the nurse to do what? A. remove the cotton balls from the kit for later use B. advance the catheter 10 to 12 inches or until urine flows C. lubricate the first 5 to 7 inches of the catheter D. hold the penis at a 45-degree angle during insertion

C. lubricate the first 5 to 7 inches of the catheter

A client with a newly formed colostomy, secondary to cancer of the rectum, received instructions regarding ostomy care and management. Which client statement indicates understanding of colostomy care? A. I will call the clinic and report if I notice a loss of sensation to touch in the stoma tissue B. I will call the clinic and report when mucus is passed from the stoma between irrigations C. I will call the clinic and report expulsion of flatus while the irrigating fluid is running out D. I will call the clinic and report if I have difficulty inserting the irrigating tube into the stoma

D. I will call the clinic and report if I have difficulty inserting the irrigating tube into the stoma

Which technique is most accurate in identifying an appropriate vein site for IV catheter insertion into the arm? A. remove any clothing that is covering the arm B. apply a warm washcloth to the arm at the proposed site C. elevate the selected arm on a pillow for 2 to 3 minutes D. apply a tourniquet to the selected arm 4 to 6 inches above the proposed site

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

Which condition would the nurse suspect in a client who complains of nocturia, bladder pain, urinary frequency, urgency, and dribbling at the end of urination with a digital rectal examination report indicating smooth, firm, and enlarged prostate tissues surrounding the urethra? A. prostatitis B. paraphimosis C. prostate cancer D. benign prostatic hyperplasia

D. benign prostatic hyperplasia

Which action would the nurse take to prevent venous thrombus formation after abdominal surgery? A. keep the client in a catch bed to elevate the knees B. have the client dangle the legs off the side of the bed C. help the client use an incentive spirometer every hour D. encourage the client to ambulate multiple times daily

D. encourage the client to ambulate multiple times daily

Which action would minimize the risk for cross-contamination while cleansing an infected abdominal surgical wound? A. cleansing the wound with sterile water B. blotting the incision with dry gauze C. wearing sterile gloves to cleanse the wound D. using a new gauze pad for each stroke while cleansing the wound

D. using a new gauze pad for each stroke while cleansing the wound

Which action should the nurse avoid before irrigating a patient's foot wound? A. assess the patient for a history of allergies to tape and irrigating solution B. review the provider's orders for the type of irrigating solution to be used C. assess the patient's pain on a scale of 0 to 10 D. warm the irrigant to body temperature in the microwave

D. warm the irrigant to body temperature in the microwave

In which order would the nurse complete these steps when administering a blood transfusion? 1. ascertain that intravenous catheter size is 18 or 20 gauge 2. check primary health care provider's prescription 3. change main line solution to normal saline 4. check client identification before hanging unit of blood 5. obtain vital signs and history of transfusions

2, 5, 1, 3, 4

Before performing a wound assessment, which nursing action would reduce the patient's risk for infection? A. taking the patient's temperature B. applying clean gloves C. assessing the wound for drainage D. assessing the dressing for drainage

B. applying clean gloves

The nurse notes that a patient's surgical wound is healing slowly. Which health problem would contribute to slow wound healing? A. osteoarthritis B. glaucoma C. deafness D. diabetes mellitus

D. diabetes mellitus

infusion of ABO-incompatible whole blood, RBCs, or components containing 10 mL or more of RBCs OR antibodies in recipient's plasma attach to antigens on transfused RBCs, causing RBC destruction

acute intravascular hemolytic reaction

antibodies to donor plasma, especially anti-IgA

anaphylactic reaction

How will the nurse minimize the risk for infection when changing a patient's IV catheter site dressing? A. use aseptic technique throughout the process B. pull the tape toward the insertion site C. remove both the gauze dressing and the tape one layer at a time D. explain the process to the patient

A. use aseptic technique throughout the process

Which action will the nurse take to minimize a patient's risk for injury when applying a dressing to an infusion site? A. use aseptic technique throughout the process B. apply a skin protectant to the skin before the intervention C. apply a transparent dressing that allows for visualization of the site D. explain the process to the patient before implementation

A. use aseptic technique throughout the process

The nurse is preparing to perform a sterile procedure for a patient. Which action will best minimize the risk of infection during the procedure? A. administer a prophylactic antibiotic before the procedure, as prescribed B. follow sterile technique during the procedure C. ensure proper hand hygiene before the procedure D. educate the patient in order to minimize movement and talking during the procedure

B. follow sterile technique during the procedure

When irrigating a wound, how would the nurse know the right amount of pressure to apply? A. calculate the wound size B. follow the general rule of keeping the pressure between 4 and 15 psi C. keep the pressure strong enough to cause moderate pain D. gentle enough that is does not create a splash off of the wound

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

While preparing a sterile field, the nurse determines that additional supplies are needed. What will the nurse do to ensure that the sterile field is maintained? A. cover the field with a sterile drape before leaving the room B. collect the necessary supplies after preparing a new sterile field C. retrieve the supplies, but instruct the patient not to touch anything on the field D. ask the assistant who has been helping with the procedure to bring the necessary supplies

D. ask the assistant who has been helping with the procedure to bring the necessary supplies

Which food or drink would the nurse instruct a client with a new colostomy to avoid because it produces large amounts of gas? A. milk B. cheese C. coffee D. cabbage

D. cabbage

The nursing assistive personnel reports to the nurse that a patient's intravenous access device dressing is wet. What would the nurse do first? A. assess the site B. instruct the NAP on how to change the dressing C. remove the device, and insert a new one D. reinforce the dressing with more gauze

A. assess the site

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

A. assessing the patient for allergies related to latex, antiseptic, tape, and/or iodine-based substances

Which action might the nurse perform to ensure that the wound drainage tubing does not pull on the insertion site? A. attach the tubing to the patient's gown with a safety pin B. tape the tubing to the patient's bed C. attach the tubing to the nearest side rail D. loop the tubing through the bed frame

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

The nurse is changing the dressing of a postoperative client. Another client has fallen near the nursing station and is unconscious. Which is the priority nursing action in this situation? A. attend to the client who lost consciousness B. delegate the dressing change to the nursing assistant C. delegate the care of the unconscious client to the nursing assistant D. complete the dressing, because the open wound may increase infection risk

A. attend to the client who lost consciousness

Which action will the nurse take to minimize a patient's risk for injury when applying a gauze dressing to an infusion site? A. avoid encircling the arm with tape B. not secure the tubing and catheter hub with tape C. secure the tubing in two different locations on the arm D. label the dressing with the date and time of application

A. avoid encircling the arm with tape

What would the nurse do if a sterile solution splashed onto a sterile field and contaminated the field during a dressing change? A. collect new supplies, and prepare another sterile field B. complete the dressing change in a timely manner C. move the lip of the bottle closer to the receptacle when pouring the remaining liquid D. reposition the receptacle closer to the edge of the sterile field

A. collect new supplies, and prepare another sterile field

Which action would the nurse take to reduce the risk for wound infection when collecting a specimen for culture? A. collect the specimen while wearing sterile gloves B. collect the specimen after washing the wound with sterile water C. collect the specimen before cleansing the wound D. collect the specimen after administering prescribed pain medication

A. collect the specimen while wearing sterile gloves

What might the nurse do to improve a patient's cooperation during the removal of an IV access device? A. describe the entire procedure to the patient B. assure the patient that you will remove the IV catheter quickly C. assure the patient that the procedure will take only about 5 minutes D. tell the patient that the procedure will cause only a slight burning sensation

A. describe the entire procedure to the patient

Which measure may be taken to minimize the staff's risk for infection from a urine specimen? A. firmly securing the lid of the urine specimen container B. using a sterile urine specimen container C. using a sterile syringe to access the sampling port D. placing the urine specimen container in the refrigerator until the laboratory comes to get it

A. firmly securing the lid of the urine specimen container

How might the nurse prepare a patient to anticipate some discomfort when inserting a venous access device? A. instruct the patient to expect a sharp, quick stick B. insert the access device as quickly as possible C. apply a topical anesthetic to the area before inserting the device D. promise that the procedure will not hurt once the device has been inserted

A. instruct the patient to expect a sharp, quick stick

After applying sterile gloves, the patient states she is uncomfortable and would like to move to her left side. What is the best way for the nurse to keep the gloves sterile while waiting for nursing assistive personnel to position the patient for a sterile dressing change? A. interlocking the fingers and keeping the hands above waist level B. keeping the arms at the sides, with elbows bent and gloved hands pointing up C. leaving the room momentarily D. stepping back from the bedside where NAP are working

A. interlocking the fingers and keeping the hands above waist level

The nurse has completed an intermittent straight urinary catheterization of a female patient. Which action would the nurse delegate to nursing assistive personnel? A. measure and empty the urine B. palpate the abdomen C. ask the patient if she has any pain D. document the procedure

A. measure and empty the urine

Which evidence-based nursing intervention links to reducing catheter associated urinary tract infections in clients requiring long-term indwelling catheters? A. perform catheter care twice a day B. replace the catheter on a routine basis C. administer cranberry tablets three times a day D. administer prophylactic antibiotics twice a day for the duration of the catheter placement

A. perform catheter care twice a day

Which action would the nurse take first when a client who is receiving a blood transfusion develops fever, chills, and low back pain? A. stop the blood transfusion and infused saline B. administer the prescribed antipyretic C. obtain a prescription for an antihistamine D. notify the blood bank about the symptoms

A. stop the blood transfusion and infused saline

Which action is the nurse's priority when the nurse notices the client receiving a blood transfusion is having an acute hemolytic reaction? A. stop the blood transfusion immediately B. report to the primary health care provider C. recheck identifying tags and numbers on the client D. maintain a patent intravenous line with saline solution

A. stop the blood transfusion immediately

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

A. the nurse or nursing assistive personnel removing the catheter must employ clean technique

Which instruction might the nurse give to nursing assistive personnel regarding the care of a patient with a newly established colostomy? A. be sure to pat-dry the skin surrounding the stoma before applying the new pouch B. alert me immediately if you see any blood in the fecal matter in the pouch C. using the stoma guide, cut the pouch opening about one-eighth of an inch bigger than the stoma D. remember to change your gloves after cleaning the stoma and the surrounding skin

B. alert me immediately if you see any blood in the fecal matter in the pouch

Which technique would the nurse use in attempting to glove the second hand when donning sterile gloves? A. grasp the finger portion of the second glove and lift; then insert remaining hand into glove B. insert gloved fingers under cuff of second glove and lift glove; then slide ungloved hand into glove C. using your gloved hand, grasp the folded edge of the second glove with two fingers and place glove on nondominant hand D. don glove on non dominant hand first, then hold the glove away from body and below waist to slid glove on

B. insert gloved fingers under cuff of second glove and lift glove; then slide ungloved hand into glove

While performing an intermittent straight urinary catheterization of a female patient, the nurse inadvertently inserts the catheter into the patient's vagina. Which action would the nurse take next? A. remove the catheter, and rinse it thoroughly in sterile water for reuse B. keep the catheter in place, and begin again with a new sterile catheter C. remove the catheter, relubricate it, and insert it into the urinary meatus D. stop advancing the catheter, and notify the health care provider

B. keep the catheter in place, and begin again with a new sterile catheter

Which action would the nurse take first after observing serosanguineous drainage on the abdominal dressing of a client in the postanesthesia care unit who had an abdominal cholecystectomy? A. change the dressing B. reinforce the dressing C. replace the tape with Montgomery ties D. support the incision with an abdominal binder

B. reinforce the dressing

Which statement might the nurse make to nursing assistive personnel caring for a patient who has just had an indwelling urinary catheter removed? A. teach the patient the signs of a urinary tract infection B. tell me when and how much the patient first voids C. explain that voiding might be uncomfortable for 4 to 5 days D. assess the patient for a distended bladder before the end of the shift

B. tell me when and how much the patient first voids

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

B. the excess catheter tubing has been coiled beside the patient's inner thigh

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? A. the catheter may have traumatized the labia B. the labia have contaminated the area C. the patient's perineal area must be reassessed for infection D. the nurse must ensure that the catheter is not pulling on the bladder

B. the labia have contaminated the area

What is the purpose of a condom catheter? A. to prevent urinary tract infections B. to collect urine for an incontinent man C. to prevent the spread of sexually transmitted infections D. to protect the person from HIV infection and hepatitis B

B. to collect urine for an incontinent man

What is the purpose of using a restraint alternative? A. to prevent the person from getting out of bed B. to prevent self-injury, such as from pulling out tubes C. to punish the person who does not use the signal light D. the prevent the facility from being sued if the person is injured

B. to prevent self-injury, such as from pulling out tubes

When a nursing assistive personnel enters the room of a patient in a belt restraint, he finds the patient's gown bunched around the patient's chest and the patient asking for help. What would the NAP do? A. check the patient's blood pressure and pulse before smoothing the gown B. untie the restraint and smooth the patient's gown C. put on the call light for help D. ask the patient what specific help she would like

B. untie the restraint and smooth the patient's gown

What would the nurse do to assess a patient's risk for embolus when removing a venous access device? A. inspect the site for redness B. visualize the tip of the IV device C. palpate the site for possible edema D. ask the patient to rate any pain at the site

B. visualize the tip of the IV device

When collecting a urine specimen from an indwelling urinary catheter, which action is most likely to ensure that sufficient urine is collected? A. checking the patency of the indwelling catheter tubing B. placing the urinary collection bag below the level of the bladder C. clamping the catheter tubing for 15 minutes before collection D. asking the patient to drink a glass of water 30 minutes before the collection

C. clamping the catheter tubing for 15 minutes before collection

Which clinical response will the nurse assess to determine kidney damage in a client who develops a transfusion reaction? A. glycosuria B. blood in the urine C. decreased urinary output D. acute pain over the kidney

C. decreased urinary output

Which information would the nurse consider when planning care for the postoperative client who has a newly constructed conduit diversion? A. peristalsis of the small intestine segment assists with urine flow B. stool continuously oozes from the newly created ileal conduit C. ileal diversion conduits may provide urinary continence D. absorption of nutrients diminishes within the small intestines

C. ileal diversion conduits may provide urinary continence

What is the primary reason the nurse ensures that a patient's indwelling urinary catheter drainage tubing is free of kinks? A. kinks in the tubing cause the patient unnecessary discomfort B. kinks allow the drainage bag to become overly full C. kinks are associated with the development of urinary tract infection D. kinks result in scant, dark amber-colored urine

C. kinks are associated with the development of urinary tract infection

Which instruction might the nurse give to nursing assistive personnel when caring for a patient whose IV access device is to be removed? A. remember to wear gloves to minimize the risk for infection B. be sure to keep pressure on the site for at least 2 to 3 minutes C. let me know if you notice any bleeding on the site dressing D. make sure the patient knows to notify me if the IV site becomes painful

C. let me know if you notice any bleeding on the site dressing

Which instruction might the nurse give to nursing assistive personnel regarding the care of a patient with an intravenous access device? A. assess the IV site frequently for signs of inflammation B. be sure not to obscure the insertion site with the dressing C. let me know when you notice that the IV bag contains less than 100 milliliters D. explain the symptoms of infection to the patient

C. let me know when you notice that the IV bag contains less than 100 milliliters

Twelve hours after sustaining full-thickness burns to the chest and thighs, a client who is on nothing-by-mouth status is reporting severe thirst. The client's urinary output has been 60 mL/h for the past 10 hours. No bowel sounds are heard. Which action would the nurse take? A. give the client orange juice by mouth B. increase the client's intravenous flow rate C. moisten the client's lips with a wet 4x4 gauze D. offer the client 4 oz of water by mouth

C. moisten the client's lips with a wet 4x4 gauze

The nurse has delegated measurement of a patient's vital signs and catheter care to nursing assistive personnel. Which observation should the NAP report to the nurse immediately? A. rectal temperature of 99.6° F B. pulse rate of 88 beats per minute C. redness noted on the external urethral meatus D. 200 mL of pale yellow urine in the drainage bag

C. redness noted on the external urethral meatus

Which intervention is most beneficial in preventing a catheter-associated urinary tract infection in a postoperative client? A. pouring warm water over the perineum B. ensuring the patency of the catheter C. removing the catheter within 24 hours D. cleaning the catheter insertion site

C. removing the catheter within 24 hours

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? A. reassure the patient that the procedure will take only a few minutes B. promise to reposition the patient as soon as the catheter has been inserted C. reposition the patient in a side-lying position, with her upper leg flexed at the knee and hip D. explain to the patient that the position will allow the catheter insertion to be more efficient

C. reposition the patient in a side-lying position, with her upper leg flexed at the knee and hip

Which action would the nurse take when a client refuses to take deep breaths and cough, saying, "it's too painful" after an abdominal cholecystectomy? A. give pain medication regularly as soon as possible B. obtain a prescription to increase the client's pain medication C. schedule coughing and deep-breathing exercises after analgesic has taken effect D. substitute incentive spirometry for coughing and deep breathing

C. schedule coughing and deep-breathing exercises after analgesic has taken effect

How can the nurse ensure that a patient's IV tubing will not tug on the infusion catheter after a transparent dressing is applied to an infusion site on the arm? A. encircle the arm with tape B. secure the tubing and catheter hub with tape C. secure the tubing in two different locations on the arm D. label the dressing with the date and time of application

C. secure the tubing in two different locations on the arm

What is the most important step the nurse can take to minimize the risk of tearing a sterile glove when applying it to hands? A. using powdered sterile gloves B. keeping the fingernails trimmed and smoothly filed C. selecting the proper glove size D. drying the hands thoroughly before applying the gloves

C. selecting the proper glove size

Which action needs correction regarding insertion of an intravenous cannula for administration of fluids? A. washing hands with antibacterial soap before insertion of cannula B. using chlorohexidine at the selected site of insertion C. shaving the client's skin immediately around the insertion site D. applying protectant solutions at the site of insertion

C. shaving the client's skin immediately around the insertion site

Which protocol does not vary among institutions? A. acceptability of wearing artificial nails in patient care areas B. use of impervious transparent dressings to cover open lesions on nurse's hands during sterile procedures C. use of sterile gloves for sterile procedures D. sterile gloves are only available in "one size fits all"

C. use of sterile gloves for sterile procedures

Which action would the nurse take to reduce the risk for a catheter-associated urinary tract infection in a patient with an indwelling urinary catheter? A. wear clean gloves when inserting the catheter B. inflate the balloon on the catheter before using it C. use the smallest-size catheter possible D. empty the urine by disconnecting the catheter from the collection bag

C. use the smallest-size catheter possible

An intravenous line is inserted in the scalp vein of an infant. The parent asks why the IV is not placed in the hand. Which response by the nurse is most appropriate? A. using a scalp vein improves the absorption rate B. inserting the IV in a scalp vein decreases the need for restraints C. usually veins in the arm or hand are used, but your baby's were too small D. IV solutions are too irritating for the line to be inserted into a vein in the arm or hand

C. usually veins in the arm or hand are used, but your baby's were too small

What will the nurse do to prevent possible complications after removing an IV access device in a patient on anticoagulant therapy? A. instruct the patient to report immediately any sign of bleeding on the site dressing B. perform hand hygiene and wear clean gloves while removing the device C. encourage the patient to keep a cold compress on the site for 15 minutes D. apply firm pressure to the site with sterile gauze for 10 minutes

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

Which action is the most effective in minimizing the risk of contamination when using sterile liquids during a sterile procedure? A. touch only the outer 1½ -inch margin of the sterile field unless you are wearing sterile gloves B. assess the patient for any known allergies to the sterile solution C. compare the label of the solution with the specific solution necessary for the procedure D. avoid splashing when pouring sterile liquids onto the sterile field

D. avoid splashing when pouring sterile liquids onto the sterile field

Which instruction might the nurse give to nursing assistive personnel regarding the care of a patient with an intravenous site dressing? A. assess the IV site frequently for signs of inflammation B. be sure not to obscure the insertion site with the dressing C. if the gauze dressing looks damp, replace it with a dry 4 × 4 gauze D. be sure to notify me if the patient reports that the IV site is painful or swollen

D. be sure to notify me if the patient reports that the IV site is painful or swollen

Which nursing action minimizes a patient's risk for injury during removal of an indwelling urinary catheter? A. using a 5-mL syringe to deflate the balloon B. using sterile scissors to cut the valve to deflate the balloon C. tugging gently on the catheter to pull the balloon through the urethra D. checking the documentation for the volume of fluid used to inflate the balloon

D. checking the documentation for the volume of fluid used to inflate the balloon

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? A. wash the site with soap and water B. allow the site to dry 1 to 2 minutes after cleansing it with chlorhexidine C. cleanse the site using a circular motion, starting at the insertion site and working outward D. cleanse the area by first swabbing horizontally, then vertically with the applicator for about 30 seconds

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

The nurse is caring for a client after surgical creation of an ostomy. The nurse observes that the stool is formed. The stool is this consistency in which part of the colon? A. ileum B. ascending C. transverse D. descending

D. descending

Which instruction would the nurse include in a teaching plan for a client who has a new colostomy and is learning how to care for the skin around the stoma? A. cut an opening about 1/3 inch larger than the stomal pattern B. avoid the use of soap and other irritating agents C. eat yogurt and drink buttermilk and parsley D. empty the pouch before it is one-third full

D. empty the pouch before it is one-third full

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? A. notify the surgeon of the bleeding B. remove the dressing, and assess the wound C. assess the patient for signs of shock. D. further assess the patient and the wound

D. further assess the patient and the wound

The spouse of a comatose client refuses to allow transfusions of whole blood because they are Jehovah's Witnesses. The client does not have a durable power of attorney for health care. Which action by the nurse is correct? A. institute the prescribed blood transfusion because the client's survival depends on volume replacement B. clarify the reason why the transfusion is necessary and explain the implications if there is not transfusion C. phone the primary health care provider for an administrative prescription to give the transfusion under these circumstances D. give the spouse a treatment refusal form to sign and notify the primary health care provide so legal action can be considered

D. give the spouse a treatment refusal form to sign and notify the primary health care provide so legal action can be considered

Which statement might the nurse make to nursing assistive personnel before delegating the collection of a routine urine sample from a patient with an indwelling urinary catheter? A. does the patient understand why the specimen is needed and why we cannot obtain it from the Foley bag? B. see if the catheter is causing the patient any problems and if he is having any pain C. please get two sterile urine collection containers from the utility room D. let me know if the urine contains blood or sediment, or appears cloudy

D. let me know if the urine contains blood or sediment, or appears cloudy

A client with a history of ulcerative colitis has a large portion of the large intestine removed, and an ileostomy is created. For which potential life-threatening complication would the nurse assess the client after this surgery? A. infection caused by the excretion of feces B. injury caused by exposed intestinal mucosa C. altered bowel elimination caused by the ostomy D. limited water reabsorption caused by removal of intestine

D. limited water reabsorption caused by removal of intestine

What direction would the nurse provide to nursing assistive personnel while establishing and maintaining a sterile field? A. this work surface is too low. choose a surface that's above your waist B. begin to establish the sterile field here on the overbed table C. be careful to touch only the outer 1-inch edge of the sterile drape D. remember, reaching over the sterile field constitutes a break in sterile technique

D. remember, reaching over the sterile field constitutes a break in sterile technique

While checking a blood product prior to administration, the nurse notices that the birth date on the blood bag and requisition do not match the birth date on the patient's identification bracelet. Which is the correct action for the nurse to take? A. be especially vigilant for adverse reactions during the infusion B. ask the patient to state his or her birth date C. correct the birth date on the blood bag and requisition D. return the blood to the blood bank

D. return the blood to the blood bank

The health care provider writes an order for a culture specimen to be collected from a patient with a dog bite wound. What would the nurse do first? A. explain the purpose of the test to the patient B. assess the level of the patient's pain at the wound site C. assess the patient for signs and symptoms of infection D. review the order to determine the type of specimen to be collected

D. review the order to determine the type of specimen to be collected

Why does the nurse need to keep the urine sterile while obtaining a sample from an indwelling urinary catheter? A. sterile technique protects the patient from microorganisms in the urine B. sterile technique protects the nurse from microorganisms in the urine C. sterile technique reduces the amount of pain caused by the procedure D. sterile technique ensures that microorganisms in the specimen are from the urine, and not the result of contamination

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

The nurse is caring for a client 5 days after the surgical creation of a colostomy. The client has displayed signs of depression since the surgery. The nurse would determine that there is some movement toward adaptation to the change in body image when the client exhibits which behaviors? A. the client discusses the necessity of the colostomy B. the client requests the nurse to change the dressing C. the client looks at the face of the nurse during care D. the client stares at the stoma during dressing changes

D. the client stares at the stoma during dressing changes

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? A. to increase oxygenation B. to reduce blood pressure C. to distract him D. to promote relaxation

D. to promote relaxation

Why does the nurse cleanse a female patient's perineum before inserting an intermittent urinary catheter? A. to encourage the bladder to drain fully B. to encourage spontaneous voiding C. to prevent bowel elimination during the procedure D. to reduce the patient's risk of urinary tract infection

D. to reduce the patient's risk of urinary tract infection

Which problem is the nurse trying to prevent by encouraging a client with a spinal cord injury to increase oral fluid intake? A. dehydration B. skin breakdown C. electrolyte imbalances D. urinary tract infections

D. urinary tract infections

All of the following factors are known to increase the risk of urinary tract infection except which one? A. history of fecal incontinence B. use of an indwelling urinary catheter C. drainage tubing is kinked D. use of plain soap instead of an antiseptic cleanser for perineal hygiene

D. 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? A. remove the dressing, inspect the wound, and reapply a new dressing B. inspect the wound and reapply the surgical dressing every 2 hours C. inspect the wound, and keep the dressing off until the health care provider arrives D. wait until the health care provider orders the removal of the surgical dressing

D. 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? A. cleanse it with normal saline B. wash it with soap and warm water C. rinse it with sterile water D. wipe it with an alcohol sponge

D. wipe it with an alcohol sponge

separation of the edges of a wound, revealing underlying tissues

dehiscence

fluid, cells, or other substances that have been discharged from cells or blood vessels slowly through small pores or breaks in cell membranes

exudate

of, relating to, or containing blood

sanguineous

of, relating to, or resembling serum

serous

Which nursing action during a focused urinary assessment would the nurse use to collect subjective client data? Select all that apply. A. inquire about painful urination B. ask the client about changes in characteristics of urination C. assess the levels of blood urea nitrogen and creatinine D. palpate the abdomen for bladder distention or masses E. inspect the urinary meatus for inflammation or discharge

A and B

Which nursing intervention would the nurse implement for client safety and quality of care when placing a short peripheral venous catheter? Select all that apply. A. choose a distal site B. use the wrist of the client C. choose the dominant hand D. do not use the arm on the side of a mastectomy E. choose a vein of appropriate length and width to fit the catheter's size

A, D, and E

While attempting to perform a straight catheterization for a male patient, the nurse advances the catheter 3 to 4 inches into the meatus but observes no urine flow. Which action would the nurse take at this time? A. continue to advance the catheter until 5 to 7 inches of the catheter tube has been introduced into the urethra B. withdraw the catheter to 1 inch, and ask the patient to cough C. encourage the patient to cough as the catheter is advanced D. apply pressure to the patient's lower abdomen over the bladder

A. continue to advance the catheter until 5 to 7 inches of the catheter tube has been introduced into the urethra

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? A. premedicate the patient with a prescribed analgesic 30 minutes before the intervention B. use a distraction technique to divert the patient's attention during the procedure C. position the patient comfortably before the intervention D. thoroughly explain the procedure to the patient

A. premedicate the patient with a prescribed analgesic 30 minutes before the intervention

Which action would the nurse take when a client reports pain and burning at a peripheral intravenous site after the nurse has flushed the saline lock with normal saline? A. remove the IV catheter and restart the saline lock in another site B. document the findings per protocol and reassess the site in 8 hours C. flush the IV catheter and saline lock again vigorously with normal saline D. change the dressing and apply a new clean dressing per IV care protocol

A. remove the IV catheter and restart the saline lock in another site

While checking a blood product prior to administration, the nurse is called away to assist with another procedure. What should the nurse do with the blood product? A. return it to the blood bank until it can be administered B. ask another nurse to administer it to the patient C. ask the nursing assistive personnel to place it in the unit refrigerator if you expect to be gone less than 30 minutes D. leave it in the patient's room

A. return it to the blood bank until it can be administered

Which clinical indicator would the nurse expect when an intravenous line has infiltrated? Select all that apply. A. heat B. pallor C. edema D. decreased flow rate E. increased blood pressure

B, C, and D

Which device is used for wound irrigation? A. 19-gauge needle attached to a 10-mL syringe B. 19-gauge needle attached to a 35-mL syringe C. sterile container held 30.5 cm above the wound D. foley irrigating syringe

B. 19-gauge needle attached to a 35-mL syringe

At which time would the nurse plan to administer morphine 2 mg by mouth every 2 hours as needed to a client who has burns on 55% of the body surface and requires dressing changes? A. 15 minutes before the dressing change B. 60 minutes before the dressing change C. along with a stool softener each time it is administered D. only if the client rates pain between 8 and 10 on the pain scale

B. 60 minutes before the dressing change

Which blood type is preferred for administration of blood to a client who has type B negative blood? A. A positive B. B negative C. O negative D. AB positive

B. B negative

Which direction to nursing assistive personnel would help to maintain a sterile field while conducting a sterile procedure? A. please see to it that nothing contaminates this sterile field while I get some additional supplies B. I'd like you to make sure that the patient doesn't reach toward the sterile field while I'm changing the dressing C. hand me the item closest to the edge of the sterile field D. place a sterile drape over these supplies for a moment while I answer my other patient's call light

B. I'd like you to make sure that the patient doesn't reach toward the sterile field while I'm changing the dressing

To which patient might the nurse apply a physical restraint? A. an 83-year-old patient with dementia and a history of wandering whose fall risk assessment indicates a high risk of falling B. a 42-year-old critical care patient with a traumatic brain injury who has repeatedly tried to pull out her shunt C. a 74-year-old patient confined to bed who is at risk of pressure ulcers D. a 60-year-old patient with dementia who seemed increasingly confused shortly after having had restraints applied for 1 hour that morning

B. a 42-year-old critical care patient with a traumatic brain injury who has repeatedly tried to pull out her shunt

Which clinical manifestation would the nurse identify as an indicator suggesting a client has urinary retention and overflow after sustaining a cerebrovascular accident? Select all that apply. A. edema B. polyuria C. frequent voiding D. suprapubic distention E. continual incontinence

C and D

The nurse is preparing to insert an intravenous catheter in a thin, emaciated client who is scheduled to begin ravenous fluid therapy. Which interventions would the nurse follow to provide high-quality care? Select all that apply. A. insert an 18-gauge IV catheter B. change the IV line every 7 days C. flush the IV line with normal saline D. insert the IV catheter in the client's femur E. stop the insertion procedure when there is a break in technique

C and E

A client is to receive a transfusion of packed red blood cells. Which solution would the nurse use to prime the blood intravenous tubing? A. lactated ringer solution B. 5% dextrose and water C. 0.9% normal saline D. 0.45% normal saline

C. 0.9% normal saline

An adult patient is prescribed to receive a unit of packed red blood cells. Which size intravenous catheter does the patient need to safely receive this blood? A. 30-gauge B. 25-gauge C. 18-gauge D. 10-gauge

C. 18-gauge

During a 12-hour shift, a client has a 6-oz cup of tea and 360 mL of water. The client vomits 100 mL, and the instilled intravenous fluids equaled the urinary output. Which fluid balance would the nurse record for the 12-hour period? A. 240 mL B. 340 mL C. 440 mL D. 540 mL

C. 440 mL

When changing a patient's surgical dressing 24 hours postoperatively, when would the nurse apply sterile gloves? A. after performing hand hygiene at the start of the procedure B. before removing the inner dressing C. after removing the original dressing materials and performing hand hygiene a second time D. just before cleansing the wound with sterile water

C. after removing the original dressing materials and performing hand hygiene a second time

When changing the pouching system, which routine step best minimizes irritation of the skin surrounding the stoma? A. using adhesive remover B. emptying the ostomy bag only when full C. avoiding unnecessary changes of the pouching system D. wearing clean gloves

C. avoiding unnecessary changes of the pouching system

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? A. rinse off the supplies that were contaminated with urine B. cleanse the patient's urinary meatus C. replace all contaminated supplies, and begin the process again D. change the patient's bed linens

C. replace all contaminated supplies, and begin the process again

Which statement made by the nursing student about the discharge instructions to be given to a postoperative client indicates that the nurse needs to intervene? A. I should teach the client about using topical antibiotics B. I should teach the client about how to change wound dressings C. I should instruct the client about signs and symptoms of an infection D. I should instruct the client that the non-oozing wound should be cleaned with saline solution

D. I should instruct the client that the non-oozing wound should be cleaned with saline solution

The nurse instructs nursing assistive personnel regarding proper technique for intermittent straight catheterization of a male patient. Which statement made by NAP indicates that the instruction was effective? A. I'll help you set up the sterile field B. I'll get a sterile urine cup for you C. there are leg straps in the utility room D. I'll help keep his legs away from the sterile field

D. I'll help keep his legs away from the sterile field

Which restraint alternative could be used to prevent a confused person from wandering into another person's room? A. a floor cushion next to the bed B. a bed or chair alarm C. a padded hip protector D. a knob guard on the door

D. a knob guard on the door

Which of the following technique(s) is/are best for minimizing a patient's risk for injury when inserting a venous access device? A. inserting the needle with the bevel up B. using a vein on the dorsal surface of the arm C. holding the skin taut directly below the site D. all of the above

D. all of the above

A client receiving a blood transfusion reports itching and difficulty breathing. Upon assessment the nurse notes an increased heart rate and low blood pressure. Which type of shock would the nurse suspect the client is experiencing? A. septic shock B. cariogenic shock C. neurogenic shock D. anaphylactic shock

D. anaphylactic shock

A client has a large, open abdominal wound. The health care provider's prescription states to cleanse the wound with normal saline, pack it with damp gauze, cover with abdominal pads, and secure with Montgomery straps twice a day. Which step would the nurse take to maintain sterility when changing the dressing? A. use two square gauze pads to cleanse the wound, one for each half of the wound B. apply new Montgomery straps each the dressing is changed C. hold the wet gauze with the tips of the forceps higher than the wrist D. cleanse the wound with wet, sterile gauze from the center of the wound outward

D. cleanse the wound with wet, sterile gauze from the center of the wound outward

What is the nursing action to set up suction for a Hemovac drainage system? A. set the suction to lowest level possible B. hemovacs are always set to medium suction C. connect to the wall on intermediate suction D. compress the hemovac, creating suction

D. compress the hemovac, creating suction

Which imaging study or diagnostic test would the nurse review to determine if the pressure injury on a patient's left heel is infected? A. white blood cell count B. complete blood count C. x-ray of left foot D. culture and sensitivity test

D. culture and sensitivity test

The nurse is placing supplies on a sterile field that is being prepared for a dressing change. Which action is likely to contaminate the field? A. placing a role of sterile tape on the field B. holding a prepackaged sterile item in the non-dominant hand while opening it C. adding supplies that will expire in 2 days D. placing the needed supplies near the back of the sterile field

D. placing the needed supplies near the back of the sterile field

When pouching a patient's colostomy, which action reduces the patient's risk for injury? A. measuring output when emptying the contents of the pouch B. maintaining the patient's bowel elimination function C. promoting the patient's autonomy with bowel elimination care D. protecting the skin from irritation caused by fecal drainage

D. protecting the skin from irritation caused by fecal drainage

The nurse is discussing the risk of falling with the wife of a patient with cognitive impairment. What is the nurse's best response when the patient's wife says, "I don't like him being tied down in the bed?" A. I'm sure you don't want him to fall again B. can you suggest an alternative? C. what did you do to prevent him from falling when he was at home? D. we will try all other alternatives before using physical restraints

D. we will try all other alternatives before using physical restraints

Which client receiving a blood transfusion who develops an adverse reaction would require immediate nursing intervention? A. itching B. flushing C. pruritus D. wheezing

D. wheezing

to come close together, as in the edges of a wound

approximate

abnormal passage from an internal organ o the surface of the body or between two internal organs

fistulas

hardening of a tissue, particularly the skin, because of edema or inflammation

induration

When teaching a client with a new colostomy about appliance care and maintenance, which information would the nurse include? Select all that apply. A. change the ostomy pouch on a routine basis B. replace the ostomy wafer weekly or sooner as needed C. remove the ostomy pouch when showering D. empty the ostomy pouch when 3/4 full of stool or gas E. empty the ostomy pouch before exercise and at bedtime

A, B, and E

What is the nurse's initial action when preparing to change a patient's colostomy pouching system? A. applying clean gloves B. draping the patient appropriately C. emptying the colostomy D. assessing the surrounding skin for signs of irritation

A. applying clean gloves

A patient requires all of the following interventions. Which one would the nurse perform last? A. change the dressing on the patient's newly established suprapubic catheter B. administer the patient's prescribed medication C. offer the patient a bedpan D. position the patient for maximum comfort and ease of breathing

A. change the dressing on the patient's newly established suprapubic catheter

Which technique would the nurse use to maintain surgical asepsis? A. change the sterile field after sterile water is spilled on it B. put on sterile gloves before opening a container of sterile saline C. place a sterile dressing no more than half an inch from the edge of the sterile field D. clean the surgical area with a circular motion, moving from the outer edge toward the center

A. change the sterile field after sterile water is spilled on it

Which question might the nurse ask the patient when an aerobic wound culture has been ordered? A. do you have any pain at the wound site? B. have you ever collected a specimen from your wound before? C. have you had any trouble breathing? D. have your blood counts been high recently?

A. do you have any pain at the wound site?

When adding a sterile liquid to a sterile field, which action will contaminate the field? A. extending your arm over the sterile field to pour the liquid into the receptacle B. holding the bottle with the label facing the palm C. adding a liquid with a usable period that expires in 2 days D. placing the receptacle 1 inch from the edge of the sterile field

A. extending your arm over the sterile field to pour the liquid into the receptacle

Which nursing action is important when transfusing packed red blood cells to a client with a diagnosis of anemia? A. assessing the client for fluid overload B. monitoring the client's response, particularly within the first 10 minutes C. assuring that the transfusion flows at a consistent rate during the procedure D. having the client tested for human immunodeficiency virus before administering the blood transfusion

B. monitoring the client's response, particularly within the first 10 minutes

Which action should the nurse take to maintain sterility when performing a dressing change? A. put the unopened sterile glove package carefully on the sterile field B. remove the sterile drape from its package by lifting it by the corners C. don sterile gloves before opening the package containing the field drape D. pour irrigation liquid from a height of at least 3 inches above the sterile container

B. remove the sterile drape from its package by lifting it by the corners

The nurse is caring for a client on bed rest. Which nursing intervention would prevent a pulmonary embolus? A. limit the client's fluid intake B. teach the client how to exercise the legs C. encourage use of the incentive spirometer D. maintain elevation of the knees at tan angle

B. teach the client how to exercise the legs

What would the nurse instruct nursing assistive personnel to report when caring for a patient in a wrist restraint? A. tell me if the patient's pulse changes B. tell me if the skin under the restraint becomes abraded or raw C. let me know if you think she's ready for them to come off D. let me know if the patient needs anything for pain

B. tell me if the skin under the restraint becomes abraded or raw

What direction would the nurse provide to nursing assistive personnel assisting with a sterile procedure in which sterile solutions are being used? A. hand me that cup of water so I can pour it over my sterile field B. would you please get me another bottle of sterile water? C. pour the sterile water into the container at the edge of the field D. open the sterile water bottle, and hold the label so that I can see it

B. would you please get me another bottle of sterile water?

Which action would minimize the risk of infection when placing prepackaged supplies on an established sterile field? A. wear clean treatment gloves B. collect supplies with sterile gloves to avoid contamination C. do not allow the wrapper to touch the sterile field D. place the supplies in the 1-inch perimeter of the sterile field

C. do not allow the wrapper to touch the sterile field

Which would the nurse include when teaching a client about the use of an incentive spirometer? A. inhale completely and exhale in short, rapid breaths B. inhale deeply through the spirometer, hold it as long as possible, and slowly exhale C. exhale completely; take a slow, deep breath; hold it as long as possible, and slowly exhale D. exhale halfway, then inhale a rapid, small breath; repeat several times

C. exhale completely; take a slow, deep breath; hold it as long as possible, and slowly exhale

A family member of a client who is prescribed a blood transfusion mentions that blood transfusions are not permitted in their faith. Which action would the nurse take to handle the situation? A. wait for the court's order to give blood to the client B. proceed with the transfusion to save the client's life C. inform the primary health care provide and not give blood to the client D. explain to the family member that the client needs this transfusion

C. inform the primary health care provide and not give blood to the client

Which strategy would the nurse determine is the best method for teaching a 4-year-old child about deep breathing before surgery? A. providing a pamphlet with pictures B. having the child blow a cotton ball across a table C. make up a game that involves using an incentive spirometer D. showing a videotape of children doing deep-breathing exercises

C. make up a game that involves using an incentive spirometer

The nurse is preparing to administer a unit of blood to a patient in the emergency department and discovers that he is not wearing an identification bracelet. What should the nurse do? A. identify the patient by asking him to produce a photo ID, such as a driver's license B. administer the blood only if you have been caring for the patient and can be certain of his identity C. return the unit to the blood bank D. identify the patient by asking a family member to identify him

C. return the unit to the blood bank

Why does the nurse instruct nursing assistive personnel to remove the wrist restraint of a confused patient every 2 hours? A. to try a less restrictive type of restraint if a more confining restraint has proved effective B. to double-check the size by inserting one finger between the wrist and the restraint C. to check the skin integrity and range of motion of the wrist D. to comply with Joint Commission standards

C. to check the skin integrity and range of motion of the wrist

Which initial nursing action would best help the patient learn self-care of a colostomy pouching system? A. giving the patient handouts on self care of a colostomy B. allowing the patient to examine an ostomy device C. identifying a family member who can participate in the ostomy appliance process D. giving the patient a handheld mirror to watch the nurse provide care

D. giving the patient a handheld mirror to watch the nurse provide care