Fundamentals 2

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?

"I am going to listen to your abdomen." The nurse should auscultate the client's abdomen to determine the presence of bowel sounds before clear liquids can be administered.

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

A halo of erythema on the surrounding skin. 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.

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?

Check the client's perineum. 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 caring for a client who post 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?

Check to determine if the catheter tubing is kinked.

A nurse is collecting a urine specimen for C&S for a client who has UTI. The client has an indwelling urinary catheter in place. Which of the following action should the nurse take?

Clamp the tubing below the collection port. The nurse should clamp the tubing below the collection port to allow fresh uncontaminated urine to collect before withdrawing the specimen through the port and placing it in a sterile specimen cup.

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

Cleanse the skin around the stoma with warm water.

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?

Collapse the device of air after emptying.

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

Collect the specimen upon arising in the morning.

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

Wipes the labia minora in an anteroposterior direction

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

Don clean gloves to remove the old dressing.

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

Exert pressure on the bony prominences when holding the eyelids open. The nurse should hold the upper lid against the eyebrow and the lower lid against the cheekbone when irrigating the eye.

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

Explain the procedure to the client. This framework assigns priority to nursing interventions that are least invasive to the client, as long as those interventions do not jeopardize client safety

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?

Montgomery straps 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

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

Offer the client tart or sour foods first. The client who has impaired pharyngeal swallowing should consume tart and sour foods at the beginning of the meal to stimulate saliva production, which helps with chewing and swallowing.

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

Pinch the NG tube while removing the tube. The nurse should pinch the NG tube while removing the tube to decrease the risk of aspiration of any gastric contents.

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

Pull suction catheter back 1 cm (0.5 in) if the client starts coughing. The nurse should pull the suction catheter back 1 cm (0.5 in) 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.

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

Purulent exudate

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

Remove the sleeve of the gown from the arm without the IV line.

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

Weigh the client on arising. The nurse should weigh the client on arising each day, after voiding, and before breakfast.

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?

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

A nurse is planning care for a group of clients who are receiving O2 therapy. Which of the following clients should the nurse plan to see first?

A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask. 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.

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

Determine whether the client is able to breathe.

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

Drop the eye medication into the lower conjunctival sac.

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

Elevate the client's head of bed 45° before the feeding.

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?

Face the client when speaking.

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

Granulation tissue fills the wound during healing.

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

Hold breath for 5 seconds after goal volume is reached. The nurse should instruct the client to hold her breath for 3 to 5 seconds after reaching maximal inspiratory volume. This decreases the collapse of alveoli, which helps to prevent the risk of atelectasis and pneumonia.

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

Hold the linens away from the body and clothing.

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

Inability of the toddler to cry or speak

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

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.

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

Lower abdomen The nurse should secure with tape the client's indwelling urinary catheter to the lower abdomen or the upper aspect of the thigh to eliminate the penoscrotal angle and prevent tissue injury.

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

Place the stool specimen collection container in a biohazard bag.

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

Renew the prescription for the use of restrains within 24 hr. The nurse should plan to renew the prescription for the restraints within 24 hr, and only after the provider has evaluated the client.

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 stimuli, has no respirations, and is pulses. Which of the following actions should the nurse take first?

Start chest compressions. The nurse should apply the safety and risk reduction priority-setting framework when caring for this client.

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

Taut skin around the IV catheter site that is cool to the touch. The client who has taut skin around the IV catheter site that is cool to touch might have an infiltrated IV site.

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

The side hip between the iliac crest and anterior iliac spine. This site is the preferred site for intramuscular injections for an adult client.

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

Turn the stocking inside out up to the heel before applying.

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

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.

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

Use the pain scale to determine the client's pain level.

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?

Vitamin C and zinc