ATI Fundamentals 2
A nurse is assessing a client who has an onset of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client? A. Does the medication you're taking relieve the pain? B. Can you point to where the pain is the worst? C. What do you think caused the onset of your pain? D. Changing positions makes your pain worse, right?
C. The nurse is using an open-ended question that allows the client to respond with a wide range of information by using more than one or two words.
A nurse is caring for an older adult client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime? A. Encourage the client to drink fluids before swallowing food. B. Offer the client tart or sour foods first. C. Tilt the client's head backward when swalling. D. Turn on the television.
B. Offer the client tart or sour foods first. The client who has impaired pharyngeal swallowing should consume tart and sour foods at the beginning of the meal to stimulate saliva production, which helps with chewing and swallowing. Other Rationales: The client who has impaired pharyngeal swallowing is at risk for choking when liquids (especially thin liquids) are offered while eating solid foods. It is preferable to suggest "dry swallows" to clear the mouth between bites of food. The client who has impaired pharyngeal swallowing should tilt the head forward to promote swallowing. The client who has impaired pharyngeal swallowing should minimize distractions at mealtimes to concentrate on chewing thoroughly and swallowing.
A nurse is providing teaching to a client who has a new colostomy about proper care. Which of the following information should the nurse include in the teaching? A. Change the colostomy bag following breakfast. B. Cleanse the skin around the stoma with warm water. C. Change the pouch every day. D. Place an aspirin in the ostomy pouch to decrease odor.
B. Cleanse the skin around the stoma with warm water. The nurse should instruct the client to cleanse the skin around the stoma with warm water, because using soap can leave a residue on the skin and cause poor adherence of the pouch adhesive. Other Rationales: The nurse should instruct the client to change the colostomy bag before a meal because drainage from the ostomy is least likely to occur. The nurse should instruct the client to change the pouch every 3 to 7 days to avoid skin breakdown around the stoma. The nurse should instruct the client not to place an aspirin in the ostomy pouch to decrease odor, because it can cause stoma bleeding.
A nurse is teaching a client who is recovering from a gallbladder surgery how to use an incentive spirometer. Which of the following information should the nurse include in the teaching? A. Exhale slowly to reach goal volume. B. Hold breath for 5 seconds after goal volume is reached. C. Continue to deep breathe between each cycle. D. Limit repeat pattern of breathing to 5 breaths.
B. Hold breath for 5 seconds after goal volume is reached. The nurse should instruct the client to hold her breath for 3 to 5 seconds after reaching the maximal inspiratory volume. This decreases the collapse of alveoli, which helps to prevent the risk of atelectasis and pneumonia Other Rationales: The nurse should instruct the client to inhale slowly to reach goal volume and to decrease collapse of alveoli in the client's lungs. The nurse should instruct the client to breathe normally for short periods of time between each cycle of breaths, to reduce hyperventilation and fatigue. The nurse should instruct the client to repeat the patterns for 10 to 20 breaths every hour while awake, which helps to prevent the risks of atelectasis and pneumonia.
A nurse is assisting a client who is eating at mealtime. The client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first? A. Place an oxygen mask on the client. B. Check the client's pulse. C. Determine whether the client is able to breathe. D. Wrap arms around the client from behind.
C. Caring for this client requires application of the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. The client is demonstrating the universal choking gesture. If the client is unable to move air in or out, severe airway obstruction is present. The client would need emergency interventions to clear a partial obstruction, indicated by stridor or minimal airway passage. As long as there is good air exchange and she can cough and breathe spontaneously, the nurse should stay with the client and monitor her condition.
A nurse is caring for a client who had a mastectomy and has a self-suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device? A. Irrigate the tubing with sterile normal water once each shift. B. Cleanse the opening with soap and water after emptying. C. Maintain the tubing above the level of the surgical incision. D. Collapse the device of air after emptying.
D. Collapse the device of air after emptying. The nurse should collapse the device of air after emptying the contents periodically to create enough suction to pull fluid exudate into the collection area of the device. Other Rationales: The nurse should keep the diaphragm of the device compressed to maintain suction and prevent clotting of sanguineous drainage. This drainage system is not made for irrigating. The nurse should cleanse the drain opening with an alcohol wipe after opening it to decrease entry of microorganisms. The nurse should maintain the drainage tubing below the level of the incision to enhance drainage.
A nurse is planning care for an adult client who has fluid volume excess. Which of the following interventions should the nurse plan to include to monitor the client's weight? A. Calibrate the scales weekly. B. Use a different scale each time. C. Weigh the client on arising. D. Weigh the client without clothing.
C. Weigh the client on arising. The nurse should weigh the client on arising each day, after voiding, and before breakfast. An accurate weight requires the client to be weighed wearing the same garments, and on the same carefully calibrated scale (balanced to zero before each use). Accurate daily weights provide the easiest measurement of volume status. An increase of 1 kg (2.2 lb) is equal to 1,000 mL (1 L) of retained fluid. Other Rationales: The nurse should calibrate the scales to 0 each day or before each use to provide accurate information. The nurse should weigh the client using the same scale each time because there generally is a slight difference between readings from each scale. The nurse should plan to have the client's weight taken wearing the same type of clothing each to provide an accurate reading and to avoid embarrassment.
A nurse is preparing to assist with an ambulation of an older adult client who was on bed rest for 3 days. Which of the following actions should the nurse take to decrease the risk of a fall? A. Use a gait belt during ambulation. B. Ensure the client is wearing socks before ambulating. C. Instruct the client to sit on the edge of the bed for 15 seconds before ambulating. D. Walk 2 feet behind the client during ambulation.
A. Use a gait belt during ambulation The nurse should use a gait belt to keep the client's center of gravity midline and decrease the risk of a fall. Other Rationales: The nurse should ensure the client is wearing nonskid shoes or slippers when ambulating to decrease the risk of a fall from slipping. The nurse should encourage the client to dangle her legs on the edge of the bed for 60 seconds before attempting to ambulate to decrease the risk of a fall caused from orthostatic hypotension. The nurse should walk beside the client to provide physical support ambulating and decrease the risk of a fall.
A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care? A. Renew the prescription for the use of restrains within 24 hr. B. Secure the restraint with the buckle side next to the client's skin C. Ensure 4 fingers can be inserted under the secured restraint D. Remove the restraint every 3 hr
A. The nurse should plan to renew the prescription for the restraints within 24 hours, and only after the provider has evaluated the client.
A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first? A. Apply a fecal collection system. B. Apply a barrier cream. C. Cleanse and dry the area. D. Check the client's perineum.
D. Check the client's perineum. Caring for this client requires application of the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. The priority nursing action is for the nurse to collect more data by assessing the area of irritation.
A nurse is planning care for a group of clients who are receiving oxygen therapy. Which of the following clients should the nurse plan to see first? A. A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask B. A client who has emphysema and is receiving oxygen at 3L/min via a transtracheal oxygen cannula C. A client who has an old tracheostomy and is receiving 40% humidified oxygen via tracheostomy collar. D. A client who has COPD and is receiving oxygen at 2L/min via nasal cannula.
A. A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask. The nurse should apply the safety and risk reduction priority-setting framework. The nurse should frequently check the bag on a rebreather mask to ensure it inflates properly. If the bag is deflated, the client will rebreathe his own exhaled carbon dioxide instead of receiving the prescribed oxygen dose. Therefore, the nurse should first see the client who has heart failure and is receiving 100% oxygen via a partial rebreather mask. Oxygen is a gas which can cause toxicity and is highly combustible, and higher concentrations of oxygen increase the risk of client injury. Other Rationales: Routine treatment for chronic lung conditions can include use of a transtracheal oxygen cannula; therefore, there is another client the nurse should plan to see first. The client will learn to use this device on his own, and the system can provide adequate oxygenation with a low flow rate of oxygen. Three liters per minute of oxygen is the equivalent of 32% oxygen delivery. Routine treatment for a client who has an old tracheostomy includes administration of humidified oxygen or air via tracheostomy collar. Therefore, there is another client the nurse should plan to see first. The nurse should use humidification to promote loosening of respiratory secretions and prevent cannula obstruction. Forty percent oxygen is the equivalent of administering oxygen at 6L/min. Routine treatment for a client who has COPD is to administer low dose therapy. Therefore, there is another client the nurse should plan to see first. Clients who have COPD depend on a low oxygen level to drive their respiratory rate. Two liters per minute of oxygen is the equivalent of 28% oxygen delivery.
A nurse is caring for a client who is postoperative and who has an indwelling urinary catheter to gravity drainage. The nurse notes no urine output in the past 2 hr. Which of the following actions should the nurse take first? A. Check to determine if the catheter tubing is kinked. B. Palpate the bladder. C. Obtain a prescription to irrigate the catheter with 0.9% sodium chloride. D. Encourage the client to drink more fluids.
A. Check to determine if the catheter tubing is kinked. The nurse should apply the least invasive priority-setting framework when caring for this client. This framework assigns priority to nursing interventions that are least invasive to the client, as long as those interventions do not jeopardize client safety. The nurse should take interventions that are not invasive to the client before interventions that are invasive. This reduces the number of organisms introduced into the body, decreasing the number of facility-acquired infections. The first action the nurse should take is to inspect the tubing carefully, straightening out any kinks, and make certain that there are no dependent loops. A common reason a tube is not draining is that there is a kink in the tubing or that the client is lying on it.
A nurse is planning care for a client who has a prescription for collection of a sputum specimen for culture and sensitivity. Which of the following actions should the nurse take when obtaining the specimen? A. Collect the specimen upon arising in the morning. B. Force fluids during the day and collect the specimen in the evening. C. Collect the specimen after antibiotics have been started. D. Collect 2 mL of sputum before sending the specimen to the laboratory.
A. Collect the specimen upon arising in the morning. The nurse should plan to collect the sputum specimen when the client arises in the morning because the client is able to more easily cough up the secretions that have accumulated during the night. Generally, the deepest specimens are obtained in the early morning, and it is preferable to collect the specimen before breakfast. The nurse should instruct the client to rinse the mouth, take a deep breath, and cough prior to expectorating into the sterile container. Other Rationales: The nurse should encourage the client to force fluids, especially clear liquids, to help to thin respiratory secretions. However, evening hours are not the preferred time for obtaining a deep sputum specimen. The nurse should collect the sputum specimen ordered for culture and sensitivity before the client receives antibiotic therapy to prevent interference with the laboratory results. The nurse should collect 4 to 10 mL of sputum before sending the specimen to the laboratory to provide an adequate amount of sputum to test for culture and sensitivity
A nurse is replacing the surgical dressings on a client who had abdominal surgery. Which of the following actions should the nurse take? A. Don clean gloves to remove the old dressing. B. Loosen the dressing by pulling tape away from the wound. C. Remove the entire old dressing at once. D. Open sterile supplies after applying sterile gloves.
A. Don clean gloves to remove the old dressing. The nurse should use standard precautions by applying clean gloves whenever there is a possibility of coming into contact with secretions. Removing a soiled dressing is a procedure that requires wearing clean, not sterile, gloves. Sterile gloves are not necessary until the nurse applies the new sterile dressing. Other Rationales: The nurse should remove the tape by loosening and pulling toward the wound or dressing to decrease tension or stress on the healing wound edges. The nurse should remove the old dressing one layer at a time to prevent the removal of drains and allow the nurse to assess the drainage. The nurse should open the sterile supplies after the removal of the old dressings, after washing her hands, and before applying sterile gloves to apply the sterile dressing to prevent microorganisms from contaminating the sterile field.
A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when instilling the eye drops? A. Drop the eye medication into the lower conjunctival sac. B. Apply gentle pressure in the outer opening of the eye for 2 min. C. Hold the eye dropper 0.5 cm (0.2 in) from the cornea. D. Instruct the client to close eyes tightly after administration.
A. Drop the eye medication into the lower conjunctival sac. The nurse should drop the eye medication in the lower conjunctival sac to avoid placing the drops on the cornea and causing damage. Other Rationales: The nurse should apply gentle pressure to the nasolacrimal duct after instilling the eye medication for 30 to 60 seconds to keep the medication from running down the duct or out of the eye. The nurse should hold the eye dropper 1 to 2 cm (0.4 to 0.8 in) from the lower conjunctival sac to protect the cornea of the eye from injury by preventing the tip of the dropper touching the eye. The nurse should instruct the client to close eyes gently when applying ointment or liquid to distribute the medication and to avoid expelling the medication or injuring the eye.
A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take? A. Pull suction catheter back 1 cm (0.5 in) if the client starts coughing. B. Allow 30 seconds between suctioning passes. C. Hyperventilate the client with 50% oxygen for 30 seconds. D. Perform a maximum of 4 passes with the suction catheter.
A. Pull suction catheter back 1 cm (0.5 in) if the client starts coughing. The nurse should pull the suction catheter back 1 cm when the client starts to cough, or resistance is met. This will remove the catheter from the mucosal wall of the trachea prior to suctioning. Other Rationales: The nurse should allow at least 1 min between suctioning passes to prevent hypoxia and to hyperventilate the client. The nurse should hyperventilate the client with 100 % oxygen for at least 2 min before suctioning to decrease hypoxia. The nurse should perform a maximum of 3 passes with the suction catheter because suctioning can cause hypoxia and induce dysrhythmia.
A nurse is helping a client change his hospital gown. The client has an IV infusion on an infusion pump. Which of the following actions should the nurse take first? A. Remove the sleeve of the gown from the arm without the IV line. B. Slow the infusion using the roller clamp. C. Disconnect the IV line from the pump. D. Bring the IV solution and tubing from the outside to the end side of the sleeve of the gown.
A. Remove the sleeve of the gown from the arm without the IV line. According to evidence-based practice, the nurse should first remove the gown from the client's arm without the IV line. Beginning this process will enable the nurse to move the gown fully off the client and last stop the system to remove the gown off the line, resulting in minimal interruption of the IV flow.
A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. Which of the following actions should the nurse take first? A. Start chest compressions. B. Provide breaths with a manual resuscitation bag. C. Administer oxygen. D. Establish an airway.
A. Start Chest Compressions (ABC normally, but CAB with CPR/Codes) The nurse should apply the safety and risk reduction priority-setting framework when caring for this client. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC Priority-Setting Framework, or Nursing knowledge to identify which risk poses the greatest threat to the client. The nurse should perform cardiopulmonary resuscitation, which starts with chest compression, then opening the airway, and breathing for adults and pediatric clients because evidence indicates there is a great survival rate when chest compressions are started before a breath is initiated.
A nurse is planning to administer pain medication to a client who has pain following an abdominal surgery. Which of the following actions should the nurse take first? A. Use the pain scale to determine the client's pain level. B. Discuss the adverse effects of pain medication with the client. C. Obtain the client's vital signs. D. Check the client's allergies.
A. Use the pain scale to determine the client's pain level. The nurse should consider Maslow's hierarchy of needs, which includes five levels of priority when caring for this client. The first level consists of physiological needs; the second level consists of safety and security needs; the third level consists of love and belonging needs; the fourth level consists of personal achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and cope with life situations. When applying Maslow's hierarchy of needs priority-setting framework, the nurse should review physiological needs first. The nurse should then address the client's needs by following the remaining four hierarchal levels. It is important, however, for the nurse to consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the specific client situation. The fourth level of Maslow's hierarchy of needs includes usefulness, self-worth, and self-confidence in fulfilling self-esteem needs. Therefore, to meet the client's physiological needs, the first action the nurse should take is to begin pain management by asking the client to describe her pain.
A nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the client's diet? A. Vitamin C and zinc B. Vitamin D C. Vitamin K and iron D. Calcium
A. Vitamin C and zinc The client's body needs both vitamin C and zinc to help fight a wound infection. The client should receive a multivitamin, and a mineral supplement of both. In addition, vitamin E supplements also are needed to aid in skin and wound healing. Other Rationales: Vitamin D is important when used with calcium to prevent osteoporosis; however, it does not assist in the client's wound healing. The main function of vitamin D is to maintain normal calcium and phosphorus levels in the blood and it may protect against cancer. Vitamin K is important for normal clotting of blood and for impaired intestinal synthesis caused from antibiotics. Iron is needed to rebuild RBCs for a client; however, neither is needed directly in the client's wound healing. Calcium is administered to prevent osteoporosis when used with vitamin D; however, it does not assist in the client's wound healing.
A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription reads: clear liquids; advance diet as tolerated. Which of the following responses should the nurse make? A. Lunch trays should be here within the hour. B. I am going to listen to your abdomen. C. I'll get you some water to drink. D. I would wait a bit, or you could feel sick.
B. A common reason clients experience nausea and vomiting after surgery is delayed gastric emptying time or decreased peristalsis. The nurse should auscultate the client's abdomen to determine the presence of bowel sounds before clear liquids can be administered.
A nurse is changing the bed linens for a client who is on bed rest. Which of the following actions should the nurse plan to take? A. Place the soiled linens on the chair while making the bed. B. Hold the linens away from the body and clothing. C. Place the linens on the floor until able to pace it in a linen bag. D. Shake the clean linens to unfold.
B. Hold the linens away from the body and clothing. The nurse should hold the linens away from the body and clothing to prevent soiling or the transfer of microorganisms. The microorganisms present on the nurse's clothing can expose other clients to microorganisms. Other Rationales: The nurse should place the soiled linens in a linen bag immediately after removing the linen from the bed to prevent the spread of microorganisms on surfaces within the client's room and exposure to personnel. Soiled linen is contaminated with microorganisms and will further contaminate the floor and attract any microorganisms present on the floor, which places the nurse and the client at risk for infection. Opening linens by shaking them causes movement of air. Air currents can carry dust and spread microorganisms throughout the room, which places the client and the nurse at risk for infection.
A nurse is caring for a toddler at a well-child visit when the mother calls to the nurse, "Help! My baby is choking on his food." Which of the following findings indicates the toddler has an airway obstruction? A. Flushing of the skin B. Inability of the toddler to cry or speak C. Presence of nausea and mild emesis D. Capillary refill time 1.5 sec
B. Inability of the toddler to cry or speak. When the client has no sound passing through the vocal cords, the nurse should identify a complete airway obstruction is evident. The nurse should use the Heimlich maneuver to dislodge whatever is obstructing the trachea. Other Rationales: The nurse should identify cyanosis as a finding associated with poor oxygenation, which could indicate an airway obstruction. The nurse should check the skin, nail beds, and mucous membranes to identify the presence of cyanosis. The presence of mild emesis does not indicate an airway obstruction. The nurse should monitor the client to ensure the client clears emesis from the oral cavity in order to prevent the airway from becoming obstructed. The expected finding for capillary refill time or blanch testing of the nail bed is less than 2 seconds; therefore, the nurse should not identify this finding as an indication of airway obstruction. Delayed capillary refill time can indicate circulatory impairment.
A nurse is preparing to anchor with tape the catheter tube for a male client who has a newly inserted indwelling urinary catheter. At which of the following locations should the nurse tape the catheter? A. Lateral thigh B. Lower abdomen C. Medial thigh D. Mid-abdominal region
B. Lower abdomen The nurse should secure with tape the client's indwelling urinary catheter to the lower abdomen or the upper aspect of the thigh to eliminate the penoscrotal angle and prevent tissue injury.
A nurse is changing the dressings for a client who has two Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation? A. Abdominal binder B. Montgomery straps C. Hypoallergenic tape D. Plastic tape
B. Montgomery Straps The nurse should apply the least restrictive priority-setting framework. This framework assigns priority to nursing interventions that are least restrictive to the client, as long as those interventions do not jeopardize client safety. Least restrictive interventions promote client safety without using restraints. The nurse should only use physical or chemical restraints when the safety of the client, staff, or others is at risk. The nurse should plan to use Montgomery straps to minimize irritation to the skin near the incisional area. Montgomery straps are adhesive strips applied to the skin on either side of the surgical wound. The adhesive strips have holes for using gauze to tie the dressing securely. When the dressing is changed, the ties are released, the dressing replaced, and the ties secured again without removing the adhesive strips. Other Rationales: An abdominal binder can hold the dressings in place and decrease skin irritation while the client rests in bed, however, when the client ambulates, the dressings tend to slide out. Securing the dressings first is the preferred method when applying a binder. Therefore, the nurse should use a less restrictive intervention first. Hypoallergenic tape is used when a client is sensitive to adhesive material; however, hypoallergenic tape can cause skin sensitivity when frequently removed and reapplied. The nurse should use a less restrictive intervention first. Plastic tape adheres well to skin and can cause skin sensitivity when frequently removed and reapplied. However, the nurse should use a less restrictive intervention first.
A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injection? A. The lower, medial quadrant of the buttock near the coccyx B. The side hip between the iliac crest and the anterior iliac spine C. The tissue of the posterior upper arm D. The lower, inner thigh 4 finger widths above the patella
B. The side hip between the iliac crest and the anterior iliac spine The side hip between the iliac crest and anterior iliac spine forms the boundaries for ventrogluteal injection; therefore, this is an appropriate site for the nurse to select. This site is the preferred site for intramuscular injections for an adult client. The nurse should prepare for injection by placing a hand on the client's greater trochanter (right hand on left hip, for example) with the first two fingers touching the iliac crest and anterior superior iliac spine, forming a "V" shape. Other Rationales: To administer intramuscular medication using the dorsogluteal site, the nurse should select the upper, lateral quadrant of the buttock. However, the nurse should recognize this site can increase risk of injury to the client because the medication is more likely to be injected into subcutaneous tissue, and there is increased risk of piercing the sciatic nerve. The nurse should select the outer, posterior tissue of the upper arm when preparing to administer a subcutaneous injection. For intramuscular injections of less than 1 mL, the nurse may select the deltoid muscle by placing four fingers on the deltoid muscle with the top finger on the acromion process. The injection site then is three finger widths below the acromion process, or about 5 cm (2 in). To administer intramuscular medication using the vastus lateralis site, the nurse should select the middle portion of the muscle from the midline of the thigh to the midline of the outer side of the thigh. The nurse can place one hand below the greater trochanter and the other hand just above the knee to locate middle portion of the muscle for the injection site.
A nurse is performing a straight urinary catheterization for a female client who has urinary retention. Which of the following actions indicates the nurse is maintaining sterile technique. A. Applies sterile gloves to open catheter package. B. Wipes the labia minora in an anteroposterior direction. C. Spreads the labia with the dominant hand. D. Uses one cotton ball to wipe the right and left labia majora.
B. Wipes the labia minora in an anteroposterior direction. The nurse should wipe anteroposterior both the right and left labia minora with separate cotton swabs to destroy any microorganisms in the area that would contaminate the catheter. Other Rationales: The nurse should apply sterile gloves after opening the catheter package to maintain aseptic technique, because the outside of the package is not considered sterile. The nurse should use the nondominant hand to spread the labia and provide the optimal view of the urethral meatus. The nondominant hand is considered contaminated once the hand touches the client's skin. The nurse should use a separate cotton ball to wipe the right and left labia majora to destroy any microorganisms on the skin surface that would contaminate the catheter.
A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take? A. Auscultate for bowel sounds after each feeding. B. Ensure the formula is cold before administering C. Elevate the client's HOB 45 degrees before the feeding. D. Flush the tubing with 15 mL of water after the enteral feeding.
C. Elevate the client's HOB 45 degrees before the feeding. The nurse should elevate the client's head of bed between 30° to 45° to prevent aspiration. Other Rationales: The nurse should auscultate for bowel sounds before each feeding to ensure the client has peristalsis bowel activity for the digestive system to digest or absorb the enteral nutrition. The nurse should ensure the formula is at room temperature before administering because cold formula might cause the client to have intestinal cramping and discomfort. The nurse should flush the tubing with at least 30 mL of water after the enteral feeding to maintain patency of the feeding tube.
A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take? A. Hold the irrigator 1.25 cm (0.5 in) above the eye B. Direct the irrigation solution upward toward the upper eyelid C. Exert pressure on the bony prominences when holding the eyelid open. D. Direct the irrigation from the outer canthus to the inner canthus of the eye
C. Exert pressure on the bony prominences. The nurse should hold the upper lid against the eyebrow and the lower lid against the cheekbone when irrigating the eye. Other Rationales: The nurse should hold the irrigator 2.5 cm (1 in) above the eye to prevent the irrigator from touching the eye and to prevent the solution from damaging the eye tissue. The nurse should direct the irrigation solution onto the lower conjunctiva sac to prevent injuring the cornea and having contaminated fluid flow down the nasolacrimal duct. The nurse should direct the irrigation solution from the inner canthus to the outer canthus of the eye to prevent injuring the cornea and having contaminated fluid flow down the nasolacrimal duct.
A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first? A. Provide the client with a glass of water. B. Assist the client to a sitting position. C. Explain the procedure to the client. D. Measure the length of tubing to be inserted.
C. Explain the procedure The nurse should apply the least invasive priority-setting framework when caring for this client. This framework assigns priority to nursing interventions that are least invasive to the client, as long as those interventions do not jeopardize client safety. The nurse should take interventions that are not invasive to the client before interventions that are invasive. (This reduces the number of organisms introduced into the body, decreasing the number of facility-acquired infections.) Informing the client about the procedure reduces fear and assists in gaining the client's cooperation, which is important for NG tube insertion and is the priority nursing intervention.
A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take? A. Lubricate up to 3.2 cm (1.25 in) of the tip of the rectal tube. B. Position the client on his right side. C. Insert the tip of the tubing 8 cm (3.1 in). D. Hold the enema container 61 cm (24 in) above the rectum.
C. Insert the tip of the tubing 8 cm (3.1 in). The nurse should insert the tip of the tubing 7 to 10 cm (3 to 4 in) along the rectal wall to prevent dislodging of the tube during the procedure and injury to the rectal mucosa. Other Rationales: The nurse should lubricate 5 to 8 cm (2 to 3 in) of the tip of the rectal tube before inserting to decrease the risk of irritation or injury to the mucosa. The nurse should position the client on the left side in the Sims' position to allow the solution to flow downward into the sigmoid colon and rectum and promote retention of the enema. The nurse should hold the enema container a maximum of 45 cm (18 in) above the rectum to prevent painful distention of the colon.
A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take? A. Maintain suction while removing the NG tube. B. Instill 100 mL of air into the NG tube before removal. C. Pinch the NG tube while removing the tube. D. Instruct the client to breathe in and out during the removal of the NG tube.
C. Pinch the NG tube while removing the tube. The nurse should pinch the NG tube while removing the tube to decrease the risk of aspiration of any gastric contents. Other Rationales: The nurse should disconnect the NG tube from the suction apparatus before removal to decrease injury to the gastrointestinal mucosa. The nurse should instill 50 mL of air into the tube to clear the contents of gastric drainage and decrease the risk of aspiration on removal of the tube. The nurse should instruct the client to take a deep breath and to hold it during the removal of the NG tube to close off the glottis and decrease the risk of aspiration of any gastric contents.
A nurse is caring for a client who is receiving an IV fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site? A. Redness at the IV catheter entry site. B. A palpable cord is felt along the vein used for the infusion. C. Taut skin around the IV catheter site that is cool to the touch. D. Bleeding at the IV insertion site.
C. Taut skin around the IV catheter site that is cool to the touch. The client who has taut skin around the IV catheter site that is cool to touch might have an infiltrated IC site. The nurse should stop the IV infusion, elevate the extremity, and apply warm moist compress, or a cold compress according to the type of infiltration. Other Rationales: The client who has redness at the IV catheter entry site might have a local infection. The nurse should remove the IV, clean the site with alcohol, and start a new IV line in another location. The client who has a palpable cord felt along the vein might have phlebitis, which is inflammation of the inner layer of a vein. The nurse should discontinue the infusion and start a new IV line in another location. Bleeding at the IV insertion site might indicate the IV system is not intact. The nurse should check to determine if the IV system is intact and if the catheter is within the client's vein. The nurse might need to start a new IV line in another location if the bleeding does not stop after interventions.
A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider? A. Tenderness when touched. B. Pink, shiny tissue with a granular appearance. C. Serosanguineous drainage. D. A halo of erythema on the surrounding skin.
D. A halo of erythema on the surrounding skin. The nurse should report to the provider when the client has a ring of erythema (redness) on the surrounding skin, which might indicate underlying infection. This and any other manifestation of infection, such as purulent drainage, swelling, warmth, or a strong odor, should be reported to the provider. Other Rationales: Tenderness when touched is an expected finding in a postoperative wound healing by secondary intention. Severe pain might indicate infection or underlying tissue destruction and should be reported. Pink, shiny tissue with a grainy appearance is granulation tissue and indicates the proliferative stage of wound healing. This is an expected finding in a postoperative wound healing by secondary intention. Serosanguineous drainage, made up of RBCs and plasma, is an expected finding in a postoperative wound healing by secondary intention. Purulent drainage suggests an infection and should be reported.
A nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take? A. Withdraw the specimen from the drainage bag. B. Cleanse the collection port with soap and water. C. Place the specimen in a clean specimen cup. D. Clamp the tubing below the collection port.
D. Clamp the tubing below the collection port. The nurse should clamp the tubing below the collection port to allow fresh uncontaminated urine to collect before withdrawing the specimen through the port and placing it in a sterile specimen cup. Other Rationales: The nurse should use a fresh urine specimen obtained near the indwelling urinary catheter to prevent contamination. The nurse should cleanse the collection port with an antimicrobial swab to prevent contamination. The nurse should place the specimen in a sterile specimen cup to prevent contamination.
A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client? A. Speak directly into the client's impaired ear. B. Exaggerate lip movements. C. Speak loudly. D. Face the client when speaking.
D. Face the client when speaking. The nurse should always directly face the client who has a hearing impairment and stand or sit at the same level to maximize communication. Many clients who are hearing impaired combine lip reading with their residual hearing when communicating. Other Rationales: The nurse should speak toward the client's best or normal ear. Moving closer to the better ear facilitates communication. The nurse should accentuate the words, especially the consonants, so the information does not sound like mumbling. The client's ability to read lips is inhibited when using exaggerated lip movements. The nurse who speaks loudly or shouts can cause distortion of the sounds because loud sounds are at a higher pitch.
A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following information should the nurse include in the teaching? A. The wound edges are well-approximated. B. The wound is closed at a later date. C. A skin graft is placed over the wound bed. D. Granulation tissue fills the wound during healing.
D. Granulation tissue fills the wound during healing. The nurse should include in the teaching that a beefy, red tissue called granulation tissue fills the wound during healing. The wound is left open to drain and heal by secondary intention that should occur within 5 to 21 days. Open wounds place the client at an increased risk for wound infection Other Rationales: Primary intention occurs when the closing of the wound using sutures or staples occurs at the time the incision is made and the suture line edges become well-approximated during healing. Tertiary intention includes using sutures to close an open wound at a later date after the wound drains and starts to heal. Tertiary intention can include the provider placing grafted skin over the client's wound bed after a wound is left open to drain and start healing. Skin grafting is required for deeper wounds, such as full-thickness burns, and is only rarely required for surgical wounds that do not heal.
A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen? A. Instruct the client to defecate into the toilet bowl. B. Transfer the specimen to a sterile container. C. Refrigerate the collected specimen. D. Place the stool specimen collection container in a biohazard bag.
D. Place the stool specimen collection container in a biohazard bag. The nurse should place the specimen collection container in a biohazard bag with the client label placed on the container and the bag for easy identification, and to prevent contamination with microorganisms. Other Rationales: The client should defecate into a bedpan or a container for stool collection, not the toilet bowl. The nurse should place the stool specimen in a clean container using a tongue depressor (not sterile... it's poop). The nurse should send the collected stool specimen immediately to the lab after labeling the specimen properly to prevent contamination with microorganisms and prevent the specimen from getting cold.
A nurse is changing the dressings for a client who is 3 days postoperative following a cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as which of the following types of drainage? A. Sanguineous exudate B. Serous exudate C. Serosanguineous exudate D. Purulent exudate
D. Purulent exudate Purulent exudate drainage on the client's dressings is thick yellow, green and brown drainage and usually indicates wound sloughing or infection. Other Rationales: Sanguineous exudate drainage on the client's dressings indicates an accumulation of RBCs from the plasma that appears bright red on the dressings. Serous exudate drainage on the client's dressings indicates plasma from the blood and appears clear to light yellow, and is watery. Serosanguineous exudate drainage on the client's dressings indicates plasma mixed with light bloody drainage, which is typically pale yellow to blood-tinged and watery drainage.
A nurse is applying antiembolic stockings for a client who has a history of deep vein thrombosis. Which of the following actions should the nurse take when applying the stockings? A. Roll the stocking partially down if too long. B. Remove the stocking once per day. C. Bunch and pull the stocking halfway up the calf. D. Turn the stockings inside out up to the heel before applying.
D. Turn the stockings inside out up to the heel before applying. The nurse should turn the stocking inside out up to the client's heel to make the application of the stocking easier and cause less constrictive wrinkles. Other Rationales: The nurse should apply another size stocking if the stocking is too long. Rolling the stocking partially down can decrease venous return and cause skin irritation. The nurse should remove the stockings once every shift to inspect the skin and check circulation. The nurse should slide the top of the stocking up over the client's calf all at once to lessen constrictive wrinkles that can decrease venous return.
