NUR3227C PPNC2 Exam 1

When delegating input and output (I&O) measurement to assistive personnel, the nurse instructs them to record what information for ice chips? 1. Two-thirds of the volume 2. One-half of the volume 3. One-quarter of the volume 4. Two times the volume

2. One-half of the volume

A 33-yr-old male patient with a gunshot wound to the abdomen undergoes surgery, and a colostomy is formed as shown in the accompanying figure. What information should be given to the patient?

Soft, formed stool can be expected as drainage.

he nurse is preparing a blood transfusion set. Which solution should be used to prime the tubing?

0.9% sodium chloride (normal saline)

Which symptoms are warning signs of possible colorectal cancer according to the American Cancer Society guidelines? (Select all that apply.) 1. Change in bowel habits 2. Blood in the stool 3. A larger-than-normal bowel movement 4. Fecal impaction 5. Muscle aches 6. Incomplete emptying of the colon 7. Food particles in the stool 8. Unexplained abdominal or back pain

1. Change in bowel habits 2. Blood in the stool 6. Incomplete emptying of the colon 8. Unexplained abdominal or back pain

What is the removal of devitalized tissue from a wound called? 1. Debridement 2. Pressure distribution 3. Negative-pressure wound therapy 4. Sanitization

1. Debridement

A patient has hypokalemia with stable cardiac function. What are the priority nursing interventions? (Select all that apply.) 1. Fall prevention interventions 2. Teaching regarding sodium restriction 3. Encouraging increased fluid intake 4. Monitoring for constipation 5. Explaining how to take daily weights

1. Fall prevention interventions 4. Monitoring for constipation

The nurse is caring for a patient with a chest tube for treatment of a right pneumothorax. Which assessment finding necessitates immediate notification of the health care provider? 1. New, vigorous bubbling in the water seal chamber. 2. Scant amount of sanguineous drainage noted on the dressing. 3. Clear but slightly diminished breath sounds on the right side of the chest. 4. Pain score of 2 one hour after the administration of the prescribed analgesic.

1. New, vigorous bubbling in the water seal chamber.

After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the boom of the now- opened wound. Which are the priority nursing interventions? (Select all that apply.) 1. Notify the health care provider. 2. Allow the area to be exposed to air until all drainage has stopped. 3. Place several cold packs over the area, protecting the skin around the wound. 4. Cover the area with sterile, saline-soaked towels immediately. 5. Cover the area with sterile gauze and apply an abdominal binder.

1. Notify the health care provider. 4. Cover the area with sterile, saline-soaked towels immediately.

During the administration of a warm tap-water enema, a patient complains of cramping abdominal pain that he rates 6 out of 10. What nursing intervention should the nurse do first? 1. Stop the instillation. 2. Ask the patient to take deep breaths to decrease the pain. 3. Tell the patient to bear down as he would when having a bowel movement. 4. Continue the instillation; then administer a pain medication.

1. Stop the instillation.

match: 1. FiO2 2.PaCO2 3. PaO2 4. SaO2 5. SpO2 a. used to assess the adequacy of ventilation b. arterial oxygen saturation measured via pulse oximetry c. used to assess the adequacy of oxygenation d. fraction of inspired oxygen (%) e. arterial oxygen saturation measured from blood specimen

1d, 2a, 3c, 4e, 5b

The health care provider's order is 500 mL 0.9% NaCl intravenously over 4 hours. Which rate does the nurse program into the infusion pump? 1. 100 mL/hr 2. 125 mL/hr 3. 167 mL/hr 4. 200 mL/hr

2. 125 mL/hr

What is a critical step when inserting an indwelling catheter into a male patient? 1. Slowly inflate the catheter balloon with sterile saline. 2. Secure the catheter drainage tubing to the bedsheets. 3. Advance the catheter to the bifurcation of the drainage and balloon ports. 4. Advance the catheter until urine flows, then insert 1⁄4 inch more.

3. Advance the catheter to the bifurcation of the drainage and balloon ports.

Which assessment does the nurse use as a clinical marker of vascular volume in a patient at high risk of extracellular fluid volume (ECV) deficit? 1. Dryness of mucous membranes 2. Skin turgor 3. Fullness of neck veins when supine 4. Fullness of neck veins when upright

3. Fullness of neck veins when supine

A patient is admied to the hospital with severe dyspnea and wheezing. Arterial blood gas levels on admission are pH 7.26; PaCO2, 55 mm Hg; PaO2, 68 mm Hg; and , 24. How does the nurse interpret these laboratory values? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

3. Respiratory acidosis

What is the correct sequence of steps when performing wound irrigation to a large open wound? 1. Use slow, continuous pressure to irrigate wound. 2. Attach 19-gauge angiocatheter to syringe. 3. Fill syringe with irrigation fluid. 4. Place biohazard bag near bed. 5. Position angiocatheter over wound.

4, 3, 2, 5, 1

What type of restraint order would this patient fall under? A male patient is admitted with an elevated blood alcohol level. He is admitted to your unit with IV therapy running. He attempts to pull out his line. When you try to redirect him, he verbally threatens you and tries to kick you away from his bed with a purposeful aim.

Behavioral

Match: 1. Dehiscence 2. Evisceration 3. Approximated 4. Slough a. Protrusion of visceral organs through a wound opening b. Partial or total separation of wound layers c. Tough stringy substance attached to the wound bed d. Wound edges are closed/ come together

Dehiscence - b. Partial or total separation of wound layers Evisceration - a. Protrusion of visceral organs through a wound opening Approximated - d. Wound edges are closed/ come together Slough - c. Tough stringy substance attached to the wound bed

Which activity in the care of a patient with a new colostomy could the nurse delegate to unlicensed assistive personnel (UAP)?

Drain and measure the output from the ostomy.

Procedures that are classified as aseptic techniques.

Handwashing Emptying a full foley drainage bag Cleaning the ports of IV tubing prior to giving medications Wiping the bedside table prior to preparing a sterile field

The nurse is inserting a Foley catheter for an elderly client with benign prostatic hypertrophy (BPH). The technique for this procedure is classified as ...?

Sterile technique

What interventions can the nurse delegate to the AP while caring for Mr. Jones? (Select all that apply.) a Assisting with bath and hygiene b Educating about the need for supplemental oxygen c Assisting while ambulating to the bathroom d Assessing respiratory status e Obtaining vital signs with patient stable f Reapply the nasal cannula that came off during AM care

a Assisting with bath and hygiene c Assisting while ambulating to the bathroom e Obtaining vital signs with patient stable f Reapply the nasal cannula that came off during AM care

Which allergy will be important to know prior to performing a urinary catheterization? Choose all that apply a Shellfish b Iodine c Penicillin d Latex

a Shellfish b Iodine d Latex

when suctioning a client with a tracheostomy, which nursing intervention is correct? a. hyperventilate the client with room air before suctioning b. apply suction only as the catheter is being withdrawn c. insert the catheter until the cough reflex is stimulated d. remove the inner cannula before inserting the suction catheter

b. apply suction only as the catheter is being withdrawn

the nurse is caring for a clinet after surgical creation of an ostomy. the nurse observes that the stool is formed. the stool is the consistency in which part of the colon? a. ileum b. ascending c. transverse d. descending

d. descending

which instruction would the nurse give to the client having a residual urine test? a. void right after a urinary catheter is removed b. collect a specimen of urine during midstream c. attempt to void when a urinary catheter is in place d. empty the bladder before a urinary catheter is inserted

d. empty the bladder before a urinary catheter is inserted

All cells in the body are believed to have intracellular receptors for a. insulin. b. glucagon. c. growth hormone. d. thyroid hormone.

d. thyroid hormone.

A patient is scheduled to have an intravenous pyelogram (IVP) the next morning. Which nursing measures should be implemented before the test? (Select all that apply.) 1. Ask the patient about any allergies and reactions. 2. Instruct the patient that a full bladder is required for the test. 3. Instruct the patient to save all urine in a special container. 4. Ensure that informed consent has been obtained. 5. Instruct the patient that facial flushing can occur when the contrast media is given.

1. Ask the patient about any allergies and reactions. 4. Ensure that informed consent has been obtained. 5. Instruct the patient that facial flushing can occur when the contrast media is given.

Which skin-care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (Select all that apply.) 1. Frequent position changes 2. Keeping the buttocks exposed to air at all times 3. Using a large absorbent diaper, changing when saturated 4. Using an incontinence cleaner 5. Applying a moisture barrier ointment

1. Frequent position changes 4. Using an incontinence cleaner 5. Applying a moisture barrier ointment

Which skills does the nurse teach a patient with a new colostomy before discharge from the hospital? (Select all that apply.) 1. How to change the pouch 2. How to empty the pouch 3. How to open and close the pouch 4. How to irrigate the colostomy 5. How to determine whether the ostomy is healing appropriately

1. How to change the pouch 2. How to empty the pouch 3. How to open and close the pouch 5. How to determine whether the ostomy is healing appropriately

Which instructions do you include when educating a person with chronic constipation? (Select all that apply.) 1. Increase fiber and fluids in the diet. 2. Use a low-volume enema daily. 3. Avoid gluten in the diet. 4. Take laxatives twice a day. 5. Exercise for 30 minutes every day. 6. Schedule time to use the toilet at the same time every day. 7. Take probiotics 5 times a week.

1. Increase fiber and fluids in the diet. 5. Exercise for 30 minutes every day. 6. Schedule time to use the toilet at the same time every day.

An intravenous (IV) fluid is infusing slower than ordered. The infusion pump is set correctly. Which factors could cause this slowing? (Select all that apply.) 1. Infiltration at vascular access device (VAD) site 2. Patient lying on tubing 3. Roller clamp wide open 4. Tubing kinked in bedrails 5. Circulatory overload

1. Infiltration at vascular access device (VAD) site 2. Patient lying on tubing 4. Tubing kinked in bedrails

What should the nurse teach a young woman with a history of urinary tract infections (UTIs) about UTI prevention? (Select all that apply.) 1. Maintain regular bowel elimination. 2. Limit water intake to 1 to 2 glasses a day. 3. Wear coon underwear. 4. Cleanse the perineum from front to back. 5. Practice pelvic muscle exercise (Kegel) daily.

1. Maintain regular bowel elimination. 3. Wear coon underwear. 4. Cleanse the perineum from front to back.

The nurse has just witnessed her patient go into cardiac arrest. What priority interventions should the nurse perform at this time? (Select all that apply.) 1. Perform chest compressions. 2. Ask someone to bring the defibrillator to the room for immediate defibrillation. 3. Apply oxygen via nasal cannula. 4. Place the patient in the high Fowler's position. 5. Educate the family about the need for CPR.

1. Perform chest compressions. 2. Ask someone to bring the defibrillator to the room for immediate defibrillation.

The nurse is caring for a patient with an artificial airway. What are reasons to suction the patient? (Select all that apply.) 1. The patient has visible secretions in the airway. 2. There is a sawtooth pattern on the patient's EtCO2 monitor. 3. The patient has clear breath sounds. 4. It has been 3 hours since the patient was last suctioned. 5. The patient has excessive coughing.

1. The patient has visible secretions in the airway. 2. There is a sawtooth pattern on the patient's EtCO2 monitor. 5. The patient has excessive coughing.

When is the application of a warm compress to an ankle muscle sprain indicated? (Select all that apply.) 1. To relieve edema 2. To reduce shivering 3. To improve blood flow to an injured part 4. To protect bony prominences from pressure injuries 5. To immobilize area

1. To relieve edema 3. To improve blood flow to an injured part

What assessments does a nurse make before hanging an intravenous (IV) fluid that contains potassium? (Select all that apply.) 1. Urine output 2. Arterial blood gases 3. Fullness of neck veins 4. Serum potassium laboratory value in EHR 5. Level of consciousness

1. Urine output 4. Serum potassium laboratory value in EHR

Which of the following are measures to reduce tissue damage from shear? (Select all that apply.) 1. Use a transfer device (e.g., transfer board) 2. Have head of bed elevated when transferring patient 3. Have head of bed flat when repositioning patient 4. Raise head of bed 60 degrees when patient positioned supine 5. Raise head of bed 30 degrees when patient positioned supine

1. Use a transfer device (e.g., transfer board) 3. Have head of bed flat when repositioning patient 5. Raise head of bed 30 degrees when patient positioned supine

The nurse is performing discharge teaching for a patient with chronic obstructive pulmonary disease (COPD). What statement, made by the patient, indicates the need for further teaching? 1. "Pursed-lip breathing is like exercise for my lungs and will help me strengthen my breathing muscles." 2. "When I am sick, I should limit the amount of fluids I drink so that I don't produce excess mucus." 3. "I will ensure that I receive an influenza vaccine every year, preferably in the fall." 4. "I will look for a smoking-cessation support group in my neighborhood."

2. "When I am sick, I should limit the amount of fluids I drink so that I don't produce excess mucus."

Which nursing actions do you take when placing a bedpan under an immobilized patient? (Select all that apply.) 1. Lift the patient's hips off the bed and slide the bedpan under the patient. 2. After positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle. 3. Adjust the head of the bed so that it is lower than the feet, and use gentle but firm pressure to push the bedpan under the patient. 4. Have the patient stand beside the bed, and then have him or her sit on the bedpan on the edge of the bed. 5. Make sure the patient has a nurse call system in reach to notify the nurse when he or she is ready to have the bedpan removed.

2. After positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle. 5. Make sure the patient has a nurse call system in reach to notify the nurse when he or she is ready to have the bedpan removed.

Which nursing interventions should a nurse implement when removing an indwelling urinary catheter in an adult patient? (Select all that apply.) 1. Attach a 3-mL syringe to the inflation port. 2. Allow the balloon to drain into the syringe by gravity. 3. Initiate a voiding record/bladder diary. 4. Pull the catheter quickly. 5. Clamp the catheter before removal.

2. Allow the balloon to drain into the syringe by gravity. 3. Initiate a voiding record/bladder diary.

A postoperative patient with a three-way indwelling urinary catheter and continuous bladder irrigation (CBI) complains of lower abdominal pain and distention. What should be the nurse's initial intervention(s)? (Select all that apply.) 1. Increase the rate of the CBI. 2. Assess the patency of the drainage system. 3. Measure urine output. 4. Assess vital signs. 5. Administer ordered pain medication.

2. Assess the patency of the drainage system. 3. Measure urine output.

An older-adult patient is receiving intravenous (IV) 0.9% NaCl. The nurse detects new onset of crackles in the lung bases. What is the priority action? 1. Notify a health care provider. 2. Decrease the IV flow rate. 3. Lower the head of the bed. 4. Discontinue the IV site.

2. Decrease the IV flow rate.

The nurse is caring for a patient with pneumonia. On entering the room, the nurse finds the patient lying in bed, coughing, and unable to clear secretions. What should the nurse do first? 1. Start oxygen at 2 L/min via nasal cannula. 2. Elevate the head of the bed to 45 degrees. 3. Encourage the patient to use the incentive spirometer. 4. Notify the health care provider.

2. Elevate the head of the bed to 45 degrees.

An ambulatory elderly woman with dementia is incontinent of urine. She has poor short-term memory and has not been seen toileting independently. What is the best nursing intervention for this patient? 1. Recommend that she be evaluated for an overactive bladder (OAB) medication. 2. Establish a toileting schedule. 3. Recommend that she be evaluated for an indwelling catheter. 4. Start a bladder-retraining program.

2. Establish a toileting schedule.

Which nursing intervention decreases the risk for catheter- associated urinary tract infection (CAUTI)? 1. Cleansing the urinary meatus 3 to 4 times daily with antiseptic solution 2. Hanging the urinary drainage bag below the level of the bladder 3. Emptying the urinary drainage bag daily 4. Irrigating the urinary catheter with sterile water

2. Hanging the urinary drainage bag below the level of the bladder

What should the nurse teach family caregivers when a patient has fecal incontinence because of cognitive impairment? 1. Cleanse the skin with antibacterial soap, and apply talcum powder to the buttocks. 2. Initiate bowel or habit training program to promote continence. 3. Help the patient to toilet once every hour. 4. Use sanitary pads in the patient's underwear.

2. Initiate bowel or habit training program to promote continence.

There is no urine when a catheter is inserted 3 inches into a female's urethra. What should the nurse do next? 1. Remove the catheter and start all over with a new kit and catheter. 2. Leave the catheter there and start over with a new catheter. 3. Pull the catheter back and reinsert at a different angle. 4. Ask the patient to bear down and insert the catheter farther.

2. Leave the catheter there and start over with a new catheter.

The nurse is performing tracheostomy care on a patient. What finding would indicate that the tracheostomy tube has become dislodged? 1. Clear breath sounds 2. Patient speaking to nurse 3. SpO2 reading of 96% 4. Respiratory rate of 18 breaths/minute

2. Patient speaking to nurse

Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? (Select all that apply.) 1. Collection of wound drainage 2. Providing support to abdominal tissues when coughing or walking 3. Reduction of abdominal swelling 4. Reduction of stress on the abdominal incision 5. Stimulation of peristalsis (return of bowel function) from direct pressure

2. Providing support to abdominal tissues when coughing or walking 4. Reduction of stress on the abdominal incision

Which assessment findings indicate that the patient is experiencing an acute disturbance in oxygenation and requires immediate intervention? (Select all that apply.) 1. SpO2 value of 95% 2. Retractions 3. Respiratory rate of 28 breaths per minute 4. Nasal flaring 5. Clubbing of fingers

2. Retractions 3. Respiratory rate of 28 breaths per minute 4. Nasal flaring

A nurse is teaching a patient to obtain a specimen for fecal occult blood testing using fecal immunochemical testing (FIT) at home. How does the nurse instruct the patient to collect the specimen? 1. Get three fecal smears from one bowel movement. 2. Obtain one fecal smear from an early-morning bowel movement. 3. Collect one fecal smear from three separate bowel movements. 4. Get three fecal smears when you see blood in your bowel movement.

3. Collect one fecal smear from three separate bowel movements.

Which instruction should the nurse give the assistive personnel (AP) concerning a patient who has had an indwelling urinary catheter removed that day? 1. Limit oral fluid intake to avoid possible urinary incontinence. 2. Expect patient complaints of suprapubic fullness and discomfort. 3. Report the time and amount of first voiding. 4. Instruct patient to stay in bed and use a urinal or bedpan.

3. Report the time and amount of first voiding.

Which of the following describes a hydrocolloid dressing? 1. A seaweed derivative that is highly absorptive 2. Premoistened gauze placed over a granulating wound 3. A debriding enzyme that is used to remove necrotic tissue 4. A dressing that forms a gel that interacts with the wound surface

4. A dressing that forms a gel that interacts with the wound surface

Which skills can the nurse delegate to assistive personnel (AP)? (Select all that apply.) 1. Initiate oxygen therapy via nasal cannula. 2. Perform nasotracheal suctioning of a patient. 3. Educate the patient about the use of an incentive spirometer. 4. Assist with care of an established tracheostomy tube. 5. Reposition a patient with a chest tube.

4. Assist with care of an established tracheostomy tube. 5. Reposition a patient with a chest tube.

When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch? 1. A local skin infection requiring antibiotics 2. Sensitive skin that requires special bed linen 3. A stage 3 pressure injury needing the appropriate dressing 4. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

4. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

The nurse assesses pain and redness at a vascular access device (VAD) site. Which action is taken first? 1. Apply a warm, moist compress. 2. Aspirate the infusing fluid from the VAD. 3. Report the situation to the health care provider. 4. Discontinue the intravenous infusion.

4. Discontinue the intravenous infusion.

A nurse is taking a health history of a newly admied patient with a diagnosis of possible fecal impaction. Which question is the priority to ask the patient or caregiver? 1. Have you eaten more high-fiber foods lately? 2. Have you taken antibiotics recently? 3. Do you have gluten intolerance? 4. Have you experienced frequent, small liquid stools recently?

4. Have you experienced frequent, small liquid stools recently?

The patient states, "I have diarrhea and cramping every time I have ice cream. I am sure this is because the food is cold." Based on this assessment data, which health problem does the nurse suspect? 1. A food allergy 2. Irritable bowel syndrome 3. Increased peristalsis 4. Lactose intolerance

4. Lactose intolerance

Place the following steps for insertion of an indwelling catheter in a female patient in appropriate order. 1. Insert and advance catheter. 2. Lubricate catheter. 3. Inflate catheter balloon. 4. Cleanse urethral meatus with antiseptic solution. 5. Drape patient with the sterile square and fenestrated drapes. 6. When urine appears, advance another 2.5 to 5 cm. 7. Prepare sterile field and supplies. 8. Gently pull catheter until resistance is felt. 9. Attach drainage tubing.

5, 7, 2, 4, 1, 6, 3, 8, 9

Place the steps for an ileostomy pouch change in the correct order. 1. Close the end of the pouch. 2. Measure the stoma. 3. Cut the hole in the wafer to fit around the stoma and not leave skin exposed to the effluent. 4. Press the pouch in place over the stoma. 5. Remove the old pouch. 6. Trace the correct measurement onto the back of the wafer. 7. Assess the stoma and the skin around it. 8. Cleanse and dry the peristomal skin.

5, 8, 7, 2, 6, 3, 4, 1

Place the following steps for discontinuing intravenous (IV) access in the correct order: 1. Perform hand hygiene and apply gloves. 2. Explain procedure to patient. 3. Remove IV site dressing and tape. 4. Use two identifiers to ensure correct patient. 5. Stop the infusion and clamp the tubing. 6. Carefully check the health care provider's order. 7. Clean the site, withdraw the catheter, and apply pressure.

6, 4, 2, 1, 5, 3, 7

The nurse is preparing to perform nasotracheal suctioning on a patient. Arrange the steps in order. 1. Apply suction. 2. Assist patient to semi-Fowler's or high Fowler's position, if able. 3. Advance catheter through nares and into trachea. 4. Have patient take deep breaths. 5. Lubricate catheter with water-soluble lubricant. 6. Apply sterile gloves. 7. Perform hand hygiene. 8. Withdraw catheter.

7, 2, 6, 4, 5, 3, 1, 8

which statement describes negative pressure wound therapy? SATA a. a suction pump is used b. necrotizing infections are treated c. oxygen is administered under high pressure d. a low-voltage current is applied to a wound area e. chronic ulcers are reduced by removing fluids from the wound

a. a suction pump is used e. chronic ulcers are reduced by removing fluids from the wound

An appropriate technique to use during physical assessment of the thyroid gland is a. asking the patient to hyperextend the neck during palpation. b. percussing the neck for dullness to define the size of the thyroid. c. having the patient swallow water during inspection and palpation of the gland. d. using deep palpation to determine the extent of a visibly enlarged thyroid gland.

c. having the patient swallow water during inspection and palpation of the gland.

While receiving a blood transfusion, your patient develops flank pain, chills, and fever. which type of transfusion reaction would the nurse conclude that the client is experiencing? a. allergic b. pyrogenic c. hemolytic d. anaphylactic

c. hemolytic

Match the pressure injury stages with the correct definition: Stage 1 Stage 2 Stage 3 Stage 4 a. partial thickness loss of skin with exposed dermis. the wound bed is viable, pink or red, most, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not viable, and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present. These injuries commonly result from adverse microclimate and sheer in the skin over the pelvis and shear of the heel. This stage should not be used to describe moisture associated skin damage (MASD), including incontinent associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, Burns, abrasions) b. Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may proceed visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. c. Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining, and/or tunneling often occurs. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss, this is in unstageable pressure injury. d. Full thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Sloth and or escort may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Facia, muscle, tendon, ligament, cartilage, and/or bone are not exposed. If slough or eschar obscures the extent of tissue lost, this is an unstageable pressure injury.

Stage 1- b Stage 2 - a Stage 3 - d Stage 4 - c

which basic principles of surgical asepsis must the nurse consider when changing the dressing of a child with severe burns? a. a paper field must remain dry to be considered sterile b. sterile items held below the waist are considered sterile c. a 1-inch (2.5cm) border around a sterile field is considered contaminated d. sterile objects in contact with clean objects are considered contaminated e. a fenestrated drape is not considered sterile

a. a paper field must remain dry to be considered sterile c. a 1-inch (2.5cm) border around a sterile field is considered contaminated d. sterile objects in contact with clean objects are considered contaminated

You're assigned to an 88yr. old female patient who needs a peripheral IV initiated. Her weight is 56kg and a height 5'2". Her skin is dry, fragile and her veins are visible. Which steps are necessary when inserting a peripheral IV line? SELECT ALL THAT APPLY a Apply tourniquet over her sleeve 10 to 15 cm (4 to 6 inches) above the intended insertion site. b. Clean skin using an approved antiseptic agent such as 70% isopropyl alcohol and allow to dry thoroughly. c Stabilize the vein by placing the thumb proximal to the insertion site while stretching the skin in the direction of insertion. d Use the smallest-gauge and shortest catheter available and insert with the bevel up at a 10- to 15-degree angle. e Observe for blood in the flashback chamber of the catheter and advance the catheter off the needle into the vein. f Release the tourniquet once the catheter has been secured and the dressing has been applied

a Apply tourniquet over her sleeve 10 to 15 cm (4 to 6 inches) above the intended insertion site. b. Clean skin using an approved antiseptic agent such as 70% isopropyl alcohol and allow to dry thoroughly. d Use the smallest-gauge and shortest catheter available and insert with the bevel up at a 10- to 15-degree angle. e Observe for blood in the flashback chamber of the catheter and advance the catheter off the needle into the vein.

Your patient's urinalysis returns from lab with a specific gravity of 1.060. What is this indicative of? Select all that apply. a Dehydration B Reduced renal blood flow c Overhydration d This is a normal value

a Dehydration B Reduced renal blood flow specific gravity: more concentrated -> higher value

You're assigned to an 88 yr. old female patient who has a peripheral IV. When you flush the patient's peripheral IV, the patient reports pain. Upon assessment, the nurse notices a red streak that is warm to the touch. What is the nurse's initial action? a Discontinue the IV b Record a phlebitis grade of 1 C Record an infiltration grade of 3 d Apply moist compresses e Slow the IV infusion rate

a Discontinue the IV

The nurse need to collect a sputum sample from the client. In order to provide safe and effective care, the nurse instructs the patient that the following action will facilitate obtaining the specimen? (Select all that apply) a Having the client take deep breaths first b Limiting fluid intake C Asking the client to spit into a collection container d Suggesting to the client that the specimen be obtained after eating e Rinse the mouth with water before obtaining the sample

a Having the client take deep breaths first e Rinse the mouth with water before obtaining the sample

You are caring for an indwelling urinary catheter should include which of the following interventions? Select all that apply. a Remove obvious encrustations from the external catheter surface by washing it gently with soap and water. b Lay the drainage bag on the floor to allow for maximum drainage through gravity c Keep catheter bag below bladder level d Monitor for adequate urine output of 30ml or greater per hour

a Remove obvious encrustations from the external catheter surface by washing it gently with soap and water. c Keep catheter bag below bladder level d Monitor for adequate urine output of 30ml or greater per hour

which instruction would the nurse provide a client needing to collect a catch urine specimen? a. "urinate a small amount, stop flow, and then fill one half of the specimen cup" b. "collect a sample of the last urine voided during the night" c. "If anticipating a delay in delivery, keep the urine sample in a warm, dry area" d. "send the urine sample to the laboratory within 6 hours of collection"

a. "urinate a small amount, stop flow, and then fill one half of the specimen cup"

Which oxygen delivery system can deliver up to 90% FiO2? a. Non-rebreather mask b. Venturi mask c. Nasal cannula d. Simple face mask

a. Non-rebreather mask Bag needs to be fully inflated Can't be on regular medsurg floor; except palliative or hospice care Only use long term for pneumothorax b. Venturi mask 24-50%, 4-12L c. Nasal cannula Mask 6 - start humidification at 4 d. Simple face mask 6-12L, 35-50%

when teaching a client with a new colostomy about appliance crae and maintance, which information would the nurse include? 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. change the ostomy pouch on a routine basis b. replace the ostomy wafer weekly or sooner as needed e. empty the ostomy pouch before exercise and at bedtime

which technique would the nurse use to maintain surgical asepsis? a. change the sterile field after sterile water is spilled on it b. put a 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 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 outer edge toward the center

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

which nurisng interventions would provide safe oxygen therapy? SATA a. check tubing for kinks b. run wires under carpeting c. post 'no smoking' signs in the clients rooms d. place oxygen tanks flat in the carts when not in use e. make sure the client is using oil-based products to lubricate the nose

a. check tubing for kinks c. post 'no smoking' signs in the clients rooms

which nurisng intervention would the nurse implement for client safety and qaulity of acre when placing a short peripheral venous catheter? a. choose a distal site b. use the wrist of the client c. choose the dominant hand d. do not use the arm of the side of the mastectomy e. choose a vein of appropriate length and width to fit the catheter's size

a. choose a distal site d. do not use the arm of the side of the mastectomy e. choose a vein of appropriate length and width to fit the catheter's size

A patient has a total serum calcium level of 3 mg/dL (1.5 mEq/L). If this finding reflects hypoparathyroidism, the nurse would expect further diagnostic testing to reveal a. decreased serum PTH. b. increased serum ACTH. c. increased serum glucose. d. decreased serum cortisol levels.

a. decreased serum PTH.

the nurse finds that the surgical mask being worn has become moist before going into a surgery. which would the nurse do? a. dispose of the mask and put on a new one b. wait until the mask gets dry and then entering the operating room c. do not cough or sneeze while wearing the mask d. talk less after wearing the mask to minimize respiratory airflow

a. dispose of the mask and put on a new one

a client is hospitalized with pressure injuries. which task(s) could be delegated to an unlicensed assistive personnel (UAP)? a. empty wound drainage containers b. report change sin wound appearance c. apply prescribed dressings and medications d. assess and record data about wound appearance e. choose dressings and therapies for wound treatment

a. empty wound drainage containers b. report change sin wound appearance

When obtaining subjective data from a patient during assessment of the endocrine system, the nurse asks specifically about a. energy level. b. intake of vitamin C. c. employment history. d. frequency of sexual intercourse.

a. energy level.

Abnormal findings during an endocrine assessment include (select all that apply) a. excess facial hair on a woman. b. blood pressure of 100/70 mm Hg. c. soft, formed stool every other day. d. 3-lb weight gain over last 6 months. e. hyperpigmented coloration in lower legs.

a. excess facial hair on a woman. e. hyperpigmented coloration in lower legs.

a client with a chronic obstructive pulmonary disease (COPD) exacerbation is receiving oxygen at 2L/min per nasal cannula and has an oxygen saturation of 88% (0.88). which action would the urse anticipate taking next? a. increasing oxygen flow rate to 3L/min b. preparing for intubation and assisted ventilation c. administration of an inhaled rapid-acting bronchodilator d. continuing to monitor the client with no therapy change

a. increasing oxygen flow rate to 3L/min

the nurse is preparing to change a client's dressing. for which reason would the nurse use surgical asepsis? a. keeps the area free of microorganisms b. confines microorganisms to the surgical site c. protects self from microorganisms in the wound d. reduces the risk for growing opportunistic microorganisms

a. keeps the area free of microorganisms

which nursing intervention is necessary before a blood transfusion is administered? a. obtain the client's vital signs b. monitor hemoglobin and hematocrit levels c. allow the blood to reach room temperature d. determine typing and crossmatching of blood e. use a Y-type infusion set to initiate 0.9% normal saline

a. obtain the client's vital signs d. determine typing and crossmatching of blood e. use a Y-type infusion set to initiate 0.9% normal saline

which evidenced-based nursing intervention links to reducing catheter associated urinary tract infections (CUTIs) 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

the nurse is caring for a client with a tracheostomy. which action would the nurse implement when performing tracheal suctioning? a. pre-oxygenate the client before suctioning b. employ gentle suctioning as the catheter is being inserted c. loosen the clients secretions before suctioning by instilling saline d. ensure the cuff of the tracheostomy is inflated during suctioning

a. pre-oxygenate the client before suctioning

A patient has a serum sodium level of 152 mEq/L (152 mmol/L). The normal hormonal response to this situation is a. release of ADH. b. release of ACTH. c. secretion of aldosterone. d. secretion of corticotropin-releasing hormone.

a. release of ADH.

which action would the nurse take when a client reports pain and burning at a peripheral intravenous (IV) 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

which intervention is most important in preventing hospital-acquired catheter urinary tract infections (CAUTIs)? a. removing the catheter b. keeping the drainage bag off the floor c. washing hands before and after assessing the catheter d. cleansing the urinary meatus with soap and water daily

a. removing the catheter

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 infuse 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 infuse saline acute hemolytic reaction

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 acute hemolytic reaction

a postoperative client with a tracheostomy tube in place suddenly develops noisy, increased respirations and an elevated heart rate. the nurse would take which action immediately? a. suction the tracheostomy b. change the tracheostomy c. readjust the tracheostomy tube and tighten the ties d. perform a complete respiratory assessment

a. suction the tracheostomy

Endocrine disorders often go unrecognized in the older adult because a. symptoms are often attributed to aging. b. older adults rarely have identifiable symptoms. c. endocrine disorders are relatively rare in the older adult. d. older adults usually have subclinical endocrine disorders that minimize symptoms.

a. symptoms are often attributed to aging.

the nursing supervisor sends an unlicensed health care worker to help relive the burden of care on a short-staffed medical-surgical unit. which tasks can be delegated to the unlicensed health care worker? SATA a. taking routine vital signs b. applying a sterile dressing c. answering clients' call lights d. administering saline infusions e. changing linens on an occupied bed f. assessing client repsones to ambulation

a. taking routine vital signs c. answering clients' call lights e. changing linens on an occupied bed

at which site would the nurse obtain a sterile urinalysis from a client with an indwelling catheter? a. tubing injection port b. distal end of the tubing c. urinary drainage bag d. catheter insertion site

a. tubing injection port

Which nursing intervention is MOST effective in promoting effective airway clearance for this patient? A Instilling normal saline into the tracheostomy tube to thin secretions before suctioning b Administering humidified oxygen through a tracheostomy collar c Deflating the tracheostomy cuff before allowing the patient to cough up secretions d Suctioning respiratory secretions several times every hour

b Administering humidified oxygen through a tracheostomy collar Don't deflate cuff - only for HCP; usually every 8 hours and/or PRN

A nurse is selecting a site to insert an intravenous (IV) catheter on an adult. Which actions will the nurse take? SELECT ALL THAT APPLY a Use the patient's dominant arm b Check for contraindications for the site/extremity c Select a vein with minimal curvature d Avoid areas of flexion if possible e Choose a vein that feels rigid to touch — means they've used it a lot and there's scarring F Start proximally and move distally — opposite

b Check for contraindications for the site/extremity c Select a vein with minimal curvature d Avoid areas of flexion if possible

The nurse goes in to provide discharge instructions for another client who has had surgery. The client has this finding at a previous IV site. The nurse concludes that which of the following complications has occurred? a Infection b Hematoma or bruising c Infiltration d Thrombophlebitis

b Hematoma or bruising

Case study: Agitated and restless, copious amount of oral secretions, oxygen level -- What action should the nurse take first? a Apply oxygen by nasal cannula b Perform oropharyngeal suctioning c Call respiratory therapy d Place the client in a supine position E Call rapid response

b Perform oropharyngeal suctioning Clear the airway first suctioning, sit up, oxygen, call

You are the nurse taking care of Mr. Smith who is oriented to person only and only nods when asking questions. Upon assessment you notice that he has an IV infusing D5W @ 75ml/hr. You touch his site and he makes a facial grimace. You notice erythema, induration and a palpable venous cord. All these are signs of which complication? A Infiltration b Phlebitis C Anaphylaxis d Poor IV insertion site e IV fluid overload

b Phlebitis

Which action will the nurse include when doing tracheostomy care? Select all that apply a Provide Oxygen via nasal cannula when suctioning Nose if for decoration with trach b Use sterile technique when cleaning inner cannula c Use sterile cotton tipped swabs to clean inner cannula Use a special brush d Don sterile gloves before removing the inner cannula e Use Hydrogen peroxide to clean skin around the stoma Too harsh to be around the stoma, might erode f Cut a 4x4 gauze pad to use as a drain sponge if needed Trach dressings that have a special split; don't want the fibers to get in the hole g Ensure the dominant hand remains sterile

b Use sterile technique when cleaning inner cannula d Don sterile gloves before removing the inner cannula g Ensure the dominant hand remains sterile Nose if for decoration with trach; Use a special brush to clean; hydrogen peroxide too harsh to be around the stoma, might erode; Trach dressings that have a special split - don't want the fibers to get in the hole

in which order would the nurse perform the actions when collecting the urine specimen of a client who has an indwelling catheter? a. inject the urine sample into sterile specimen container b. apply a clamp to the drainage tubing distal to the injection port c. remove the clamp to resume the drainage d. clean the injection port with an antiseptic e. aspirate the quantity of the urine required f. attach a 5mL sterile syringe into the port g. dispose of the syringe

b, d, f, e, a, c, g

in which order would the nurse treat the infiltration of a nonvesciant intravenous (IV) solution leaking into the extravascular tissue? a. rate the infiltration using teh INS infiltration scale and documenr the procedure b. stop infusion and remove peripheral venous catheter c. insert a new catheter in the opposite extremity d. obtain a study to determine the cause of the problem e. apply a sterile dressing f. use warm or cold compress according to the solution infiltrated g. elevated the extremity

b, e, g, f, c, d, a

the registered nurse (RN) is evaluating the statements of new nurse about wound dressings. which statement made by the new nurse is incorrect? a. "i should wash my hands with alcohol based antiseptic." b. "i should use the cotton swab placed on the table." c. "i should wash my hands before touching the wound.: d. "i should wear gloves before touching the site of injury"

b. "i should use the cotton swab placed on the table."

which instruction is important for the nurse to include in discharge teaching for a client who has to perform intermittent urinary self-catheterization? a. "wear sterile gloves when doing the procedure" b. "wash your hands before performing the procedure" c. "perform the catheterization every 12 hours" d. "dispose of the catheter after you have catheterized yourself"

b. "wash your hands before performing the procedure"

the nurse is changing the soiled bed linens of a client with a wound that is draining serosanguinous exudate. what personal protective equipment (PPE) would the nurse wear? a. mask b. clean gloves c. sterile gloves d. shoe covers

b. clean gloves

sterile warm saline soaks three times a day are prescribed for a client with cellulitis from a puncture wound. the primary nurse places a clean basin, wash cloth, and protective pad at the bedside in preparation for the soak but is unable to continue the procedure. which step would teh new nurse assigned to complete the soak do? a. continue the procedure as started b. collect new supplies before starting c. discuss the type of soak with the primary health care provider d. report the primary nurse to the unit's nurse manager

b. collect new supplies before starting

which clinical finding leads the nurse to conclude that an IV has infiltrated rather than cause inflammation? a. pain b. coolness c. localized swelling d. cessation in flow of solution

b. coolness

which factor would the nurse recognize as the cause when a client's intravenous (IV) 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

A characteristic common to all hormones is that they a. circulate in the blood bound to plasma proteins. b. influence cellular activity of specific target tissues. c. accelerate the metabolic processes of all body cells. d. enter a cell and change the cell's metabolism or gene expression.

b. influence cellular activity of specific target tissues.

which nursing action is appropriate when suctioning the secretions of a client with a tracheostomy? a. use a new sterile catheter is being withdrawn b. initiate suction as the catheter is being withdrawn c. insert the catheter until the cough reflex is stimulated d. remove the inner cannula before inserting the suction catheter

b. initiate suction as the catheter is being withdrawn

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 fingers under cuff 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 non-dominant hand d. don glove on non-dominant hand first, then hold the glove away from the body and below waist to slide glove on

b. insert fingers under cuff second glove and lift glove; then slide ungloved hand into glove

which type of asepsis is the nurse using when he or she washes his or her hands before changing a client's postoperative dressing? a. wound asepsis b. medical asepsis c. surgical asepsis d. concurrent asepsis

b. medical asepsis

which clinical indicator would the nurse expect when an intravenous (IV) line has infiltrated? SATA a. heat b. pallor c. edema d. decreased flow rate e. increased blood pressure

b. pallor c. edema d. decreased flow rate

which cause would a nurse suspect is responsible for warmth, redness, and tenderness identified at a client's intravenous (IV) site? a. rapid fluid delivery b. phlebitis c. allergic response d. infiltration

b. phlebitis

which nursing intervention would help an older adult experiencing urinary incontinence? a. provide nutritional support b. provide voiding opportunities c. avoid indwelling catheterization d. provide beverages and snacks frequently e. promote measures to prevent skin breakdown

b. provide voiding opportunities c. avoid indwelling catheterization e. promote measures to prevent skin breakdown

which intervention would the nurse implement when providing care for an older adult male client who is immobile and incontence of urine? a. restrict the clients 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 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 (2.5 cm) above the sterile container

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

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 3inches (2.5 cm) above the sterile container

b. remove the sterile drape from its package by lifting it by the corners outer 1 inch of the sterile field is considered contaminated; must pour from 4-6 inches

which action would the nurse perform first when assessing if an intravenous (IV) infusion of a vesicant has extravasated? a. elevated the IV site b. stop the infusion c. contact the prescriber d. aspirate residual medication from the IV catheter

b. stop the infusion

why are the faucet handles on the sink in a client's room considered contaminated? a. they are not in sterile area b. they are touched by dirty hands when turning the water on c. large number of people use them each day d. water encourage bacterial growth

b. they are touched by dirty hands when turning the water on

during an assessment, the client complains of tenderness when the nurse palpates the calf muscle. which technique would be the nurse's next assessment? a. to assess for ant reduced hair growth b. to assess for swelling, warmth, and muscle firmness c. to assess for any history of ulcer formation around the calf muscle d. to assess for venous distention in the posterolateral part of ankle

b. to assess for swelling, warmth, and muscle firmness

at which time would the nurse release the tourniquet when initiating an intravenous line? a. after cleaning the insertion site b. when the needle enters the vein c. as soon as the needle pierces the skin d. after the device is secured with tape

b. when the needle enters the vein

The wall suction should be at what range when suctioning an adult patient with a tracheostomy? a 30-50 mmHg b 50 - 80 mmHg c 100 - 150 mmHg d 150-200 mmHg

c 100 - 150 mmHg 80-150 !!!

You're assigned to an 88yr. old female patient who has a peripheral IV that is saline locked. Which tasks can the nurse assign to the nursing assistive personnel?SELECT ALL THAT APPLY a Changing the IV dressing B Starting the IV fluid c Changing the client's gown d Flush the saline lock e Record oral intake and output

c Changing the client's gown e Record oral intake and output

the fmaily of an older adult reports to the nurse manager that the primary nurse failed to obtain a signed consent before inserting an indwelling catheter. which rationale would the nurse manager consider before responding? a. procedures for a client's benefit do not require a signed consent b. clients who are aphasic are incapable of signing an informed consent c. a separate signed informed consent for routine treatments is unnecessary d. a specific intervention without a client's signed consent is an invasion of rights

c. a separate signed informed consent for routine treatments is unnecessary

A patient is receiving radiation therapy for cancer of the kidney. The nurse monitors the patient for signs and symptoms of damage to the a. pancreas. b. thyroid gland. c. adrenal glands. d. posterior pituitary gland.

c. adrenal glands.

which information would the nurse consider when planning care for the postoperative client who has newly constructed conduit diversion (ileal conduit)? 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

which action would the nurse implement to prevent a client with urinary retention and an indwelling urinary catheter from developing a urinary tract infection? a. assess urine specific gravity b. collect a weekly urine specimen c. maintain the prescribed hydration d. empty the drainage bag once a day

c. maintain the prescribed hydration

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

which pice of equipment would the nurse make sure was sterile while providing care for a client? a. bedpan b. stethoscope c. suction catheter d. blood pressure cuff

c. suction catheter

five days after a client has an adbominal surgery the nurse assesses the client's incision site of dehiscence. which clinical finding supports that the client is experimceing wound dehiscence? a. increased bowel sounds b. loosening of intact sutures c. sudden increase in serosanguineous drainage d. purplish color of the incision

c. sudden increase in serosanguineous drainage

The PCA has bladder scanned an adult patient to check for a post void residual (PVR). Which amount is of concern to notify the MD? a 30ml b 95ml c 60ml d 125ml

d 125ml should be less than 100mL (if more, indicates bladder bladder scan — get post void residual

You are called into a patient room for an IV pump that is beeping occluded. Upon initial assessment of the IV site, you note that the site is cool, pale, and swollen. You conclude which complication has occured? a Infection b Phlebitis c Hematoma d Infiltration e Pump malfunction

d Infiltration

A newly admitted patient has a suprapubic catheter. You notice that the site is red and leaking urine. You notify the HCP and take priority to what course of action? a This is a normal finding b Tell patient he/she will need to go back to surgery. c Empty and record urine d Monitor urine output & provide skin care

d Monitor urine output & provide skin care

You are a nursing student watching a placement of an urinary catheter in a female client by an experienced registered nurse. You notice that there is a breech in sterility during the setup. What is your best course of action? a Notify the instructor after insertion b Keep quiet c Tell the nurse that this is not how you have learned this skill d Offer to obtain another sterile kit and state what was breeched

d Offer to obtain another sterile kit and state what was breeched

The IV is no longer being used except for IV antibiotics every 8 hours. It has been saline locked 2 hours ago. The dressing is clean and dry, loose at the side edges. What should the nurse do? a. Remove the IV and wait to start another one when the medication is due b. No action in needed just monitor c. Flush the IV and tape down the side edges d. Remove and replace the dressing

d. Remove and replace the dressing

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

a client has a large, open abdominal wound. the healthcare 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 time 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

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 (0.85 cm) 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 1/3 full

d. empty the pouch before it is 1/3 full

which infection prevention technique would be appropriate for the nurse to include when teaching a client being discharged with an indwelling catheter? a. once a day, clean the tubing with a mild soap and water, starting at the drainage bag and moving toward the insertion site b. after cleaning the catheter site, it is important to keep the foreskin retracted for 30 minutes to ensure adequate drying c. clean the insertion site daily using a suction of 1 part vinegar to 2 parts water d. keep the drainage bag below waist level

d. keep the drainage bag below waist level

which method of oxygen delivery would the nurse anticipate will be prescribed for a client with a pulse oximetry reading of 65%? a. face tent b. venturi maks c. nasal cannula d. nonrebreather mask

d. nonrebreather mask

which finding in a client who has home oxygen therapy with a tracheostomy collar requires immediate action by the home health nurse? a. condensation in the tubing b. oxygen flow rate 9 L/min c. low fluid level in the humidifier d. scented candle burning in the room

d. scented candle burning in the room

which action by the fmaily member during a return demonstration indicates the need for additional tecahing after a home health nurse teaches a fmaily member to cleanse a client's wound and apply a sterile dressing? a. placing the old dressing in a plastic bag b. changing the dressing without wearing a mask c. donning non-sterile gloves for removing the old dressing d. using a back and forth motion with the same gauze while cleaning the wound

d. using a back and forth motion with the same gauze while cleaning the wound

how would the nurse classify a wound that exhibits some soft necrotic tissue with a semiliquid slough and exudate? a. red b. black c. green d. yellow

d. yellow

What is the term for removal of devitalized tissue in a wound when appropriate for the patient's condition and consistent with the patient's goals?

debridement