Week 10/11
Which action will the nurse implement to reduce the risk of CAUTI in a male patient with an indwelling urinary catheter?
Clean the urinary meatus daily
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?
promote relaxation
The nurse is delegating to 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 3 or 4 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."
The nurse has delegated to NAP the task of performing fecal occult blood tests on the stool of a patient with a history of positive results. Which instruction is most relevant to performing this test in this particular patient?
"Save the stool sample so that I can retest it if it is positive"
Which instruction might the nurse give to NAP regarding the care of a patient with a NG tube?
"Tell me if you see any vomit in the patient's mouth during oral care"
Which statement might the nurse make to NAP caring for a patient who has just had an indwelling urinary catheter removed?
"Tell me when and how much the patient first voids"
Which statement best illustrates the nurse's understanding of the role of the NAP in carrying out a gastric occult blood test for a patient with a low hemoglobin and hematocrit?
"The next time the patient vomits, please test it for occult blood"
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.
During intermittent open bladder irrigation, a patient complains of pain. Which action would the nurse take first? A. Examine the drainage tubing for clots, sediment, and kinks. B. Notify the health care provider. C. Leave the irrigation drip wide open. D. Monitor the patient's vital signs.
Examine the drainage tubing for clots, sediment, and kinks.
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 action would the nurse take to manage continuous urinary catheter irrigation for a patient whose urine is bright red and contains clots?
Increase the irrigation drip rate.
Which patient does not have a medical condition that contraindicates placement of a nasogastric tube?
A 28-year-old patient who fractured a femur after heavy drinking
What will the nurse need before removing a patient's nasogastric tube?
A health care providers order
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?
Keep the catheter in place, and begin again with a new sterile catheter
What would the nurse do if material aspirated from a patient's nasogastric tube resembled coffee grounds in color and texture?
Notify the health care provider
Which action would be the nurse's priority when caring for a patient with a urostomy who had no urine output for 4 hours?
Notify the health care provider
What would the nurse do if he or she were not able to insert a nasogastric tube in either of a patient's nares?
Notify the physician that the attempts were unsuccessful
Which action would the nurse take to reduce the risk of infection among patient's and staff when administering an enema to an older adult patient with Dementia?
Perform hand hygiene before donning gloves
What would the nurse use to irrigate a patient's nasogastric tube after providing medications?
Purified water
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?
Replace all contaminated supplies, and begin the process again
Which actions would minimize the patient's risk for injury during insertion of an indwelling urinary catheter?
Assessing the patient for allergies related to latex, antiseptic, tape, and/or iodine based substances
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 initial step in preparing a fecal occult blood test?
Determine the patient's ability to help obtain a sample.
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
Which nursing action is appropriate when feeding gastric residual is 50 mL?
Return it to the stomach via the feeding tube.
Which instruction would the nurse give to the NAP to ensure the patient's comfort when a condom catheter is applied?
Use a hair guard before applying the condom catheter
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 NAP assigned to collect a midstream urine specimen from a patient with signs of a UTI?
"Be sure to maintain aseptic technique"
Which statement indicates proper interpretation of the results of a positive fecal occult blood test?
"Because it was positive, the patient must be asked when he or she last ate red meat."
The nurse has delegated administration of a standard enema for a 72 year old patient with constipation. Which statement made by NAP requires the nurse to follow up?
"I'll instill the solution and then check in on my other patient's until I get the call signal"
The nurse instructs NAP regarding proper technique for intermittent straight catheterization of a male patient. Which statement made by NAP indicates that the institution was effective?
"I'll keep his legs away from the sterile field"
Which statement best illustrates correct interpretation of a positive gastric occult blood test?
"If the test sample turns blue, it is positive for blood."
What might the nurse do to reduce the patient's discomfort before inserting a nasogastric tube?
Examine each naris for patency and skin breakdown.
Which instruction might the nurse give the NAP helping to care for a patient receiving bladder irrigation?
"Measure and report the patient's temperature to me every 4 hours"
Which statement best illustrates the nurse's understanding of the role of NAP when inserting an indwelling urinary catheter in a female patient?
"Please direct the light to better illuminate the patient's perineal area"
Which statement might the nurse make to 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 NAP about applying a condom catheter on a patient?
"Read the manufacturers instructions for applying the adhesive to secure the condom"
Which instruction to NAP is most relevant to the proper performance of a fecal occult blood test using a hemoccult slide?
"Remember to take samples from two different areas of the specimen"
When checking gastric aspirate from an NG tube, the nurse assesses a pH of 7. What would the nurse do next?
Anticipate a chest x-ray
What is the nurse's initial action when preparing to change a patient's colostomy pouching system?
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
What would the nurse do before providing the patient with a scheduled intermittent feeding through a nasogastric tube?
Check the NG tube placement
How could the nurse assess for patency of an NG tube being used for enteral nutrition?
Check the gastric residual volume
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
Which action is most important in reducing the risk for infection in a patient receiving open intermittent irrigation of a urinary catheter?
Cleaning the end of the drainage tubing with an antiseptic wipe before reconnecting it to the catheter
When preparing to apply a condom catheter, the nurse would do what first?
Close the door and draw the bedside curtain
While attempting to perform a straight catheterization for a male patient, the nurse advances the catheter 3 to 4 inches into the meatus but observed no urine flow. Which action would the nurse take at this time?
Continue to advance the catheter until 5 to 7 inches of the catheter tube has been introduced to the urethra
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
Why does the nurse elevate the head of the bed to 30 degrees for a patient receiving an intermittent tube feeding?
Elevating the head of the bed reduces the risk for aspiration.
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 nursing action addresses the risk for infection related to gastric occult blood testing?
Ensuring appropriate hand hygiene before and after testing
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
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
When preparing to insert an indwelling urinary catheter in a male patient, it is important for the nurse to do what?
Lubricate the first 5 to 7 inches of the catheter.
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 midline urine sample for a patient who is menstruating?
Make a note on the lab slip that the patient is menstruating
The nurse has completed an intermittent straight urinary catheterization of a female patient. Which action would the nurse delegate to NAP?
Measure and empty the urine
After unsuccessfully attempting to flush a nasogastric (NG) tube with water, what is the most appropriate action for the nurse to take?
Obtain a product designed to unclog NG tubes.
Which intervention might the nurse delegate to NAP when inserting a nasogastric tube?
Positioning the patient in a high-Fowler's position
What is the proper response to the nurse's observation that the patient's closed-system enteral feeding has 150 mL of formula remaining and that the infusion order rate is for 59 mL/hr?
Plan to check the feeding for completion within the next 3 hours
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.
How might the nurse minimize the patient's anxiety when removing a nasogastric tube?
Provide reassurance of what will happen during the procedure and talk the patient through the process
What patient care might the nurse delegate to nursing assistive personnel (NAP) when a patient's nasogastric tube is removed?
Providing the patient with mouth care
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?
Remove soiled gloves, and perform hand hygiene
What would the nurse do for a patient who is complaining of penile pain 15 mins after having a condom catheter applied?
Remove the catheter
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?
Reposition the patient in a side lying position, with her upper leg flexed at the knee and hip
What is the initial step in preparing to perform a gastric occult blood test for a patient with recurrent vomiting?
Review the medications the patient is currently taking.
Which observation indicates that instruction given to NAP in caring for a patient with an indwelling catheter has been effective?
The excess catheter tubing has been coiled beside the patient's inner thigh
Why might the nurse delegate to NAP the skill of performing a gastric occult blood test for a patient who has vomited?
This skill may be delegated if performed on vomited stomach contents
Why does the nurse clamp the nasogastric tube before removing it from a patient?
To keep any fluid from flowing out
Why would the nurse ensure that a patient's condom catheter is not twisted?
To prevent the catheter from coming off
Why does the nurse cleanse a female patient's perineum before inserting an intermittent urinary catheter?
To reduce the patient's risk of UTI
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 action would the nurse take to minimize a patient's risk for injury during urinary catheter irrigation?
Use slow, even pressure when injecting the irrigating fluid
Which action would the nurse take to reduce the risk for CAUTI in a patient with an in dwelling urinary catheter?
Use the smallest size catheter possible
Which of the following nursing actions addresses the risk for infection related to fecal occult blood testing?
Wearing clean gloves while testing
What would minimize the nurse's risk for contamination during the removal of a nasogastric tube?
Wearing treatment gloves
What would the nurse do if he or she encountered resistance when inserting a nasogastric tube?
Withdraw the tube to the nasopharynx.
Which action would best minimize a patient's risk for infection during removal of an indwelling urinary catheter?
the nurse or NAP removing the catheter must employ clean technique