Foundation chapters 15 & 22
A patient with a tracheostomy has been assessed and needs suctioning. How long will the nurse performs suction?
A maximum of 10 seconds
On evaluation of the patient after venipuncture, the nurse recognizes which findings to be unexpected?
A soft lump is noted under the skin at the venipuncture site
A male patient with urinary incontinence has been using an external condom catheter. The nurse is evaluating the patients technique of applying in the device. Which findings will indicate that the nurse should give the patient further instructions?
Spiraling the tape around the penis to secure the device
When selecting a side for a new IV line the nurse should perform which procedure?
Start with the areas proximal to the current site
A patient complains of a headache nausea and vomiting during a blood transfusion. Which action is necessary for the nurse to take immediately?
Stop the blood transfusion
A nurse is caring for a client who is receiving continues enteral feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding?
Stop the feeding
Which action would be the correct when a patient here is irrigated?
You say solution that is body temperature and have the patient hold a basin under the ear while solution is directed towards the loop of the canal
A five-year-old patient is being seen at the pediatricians office with a recently sprain ankle. What should the nurse take into conservation when applying and cold treatment to the ankle?
Young children's are more sensitive to cold
Rank order the instructions that will be given to the patient who is to collect a 24 hour urine specimen?
#1 explained importance of collecting all voiding #2 instructed patient not to allow toilet tissue or stool to enter the collection container #3 Place the collection container on ice #4 discard the first voided specimen and then collect the total volume of each void #5 collect each void in her urine had an ad to the large collection container
The nurse has just received an order for electrocardiography. Arrange the following steps in the order that the nurse will perform them
#1 perform hand hygiene and Don clean gloves #2 position the patient lying supine #3 raise those side rail and lower the bed to the lowest position #4 shave or clip hair if necessary #5 attach the leads to the patient #6 obtained a tracing
Rank order the following instructions that the nurse will tell a female patient who needed to Obtain midstream urine specimen
#1 perform hand hygiene before obtaining the specimen #2 clean the premium by wiping from front to back #3 *Voiding directly into the toilet #4 collect a small amount of urine in the container #5 discard the last of the stream of urine into the stool
When obtaining a recent urine specimen the nurse knows that it is important to catheterize the patient after the patient voids within which timeframe?
10 minutes
What is the maximum time suction shall be applied during nasal tracheal suctioning?
10 seconds
Which needle gauge will be needed for a rapid transfusion of whole blood
14 to 16 gauge
If patient is being discharged home and he's peripheral iv is to be disconnected. Following the removal of the catheter, what is the minimum length of time the nurse should hold pressure?
2 to 3 minutes
What is Melena?
A dark color stool, you can see the blood
Preparing the patient for a diagnostic examination include
Answer questions that the patient my need clarification, the patient needs to know if there is any NPO after midnight and breakfast will be held on to examination is completed, especially room or piece of equipment is required for the test, medication is needed before or during the test
What is important for the nurse to assess when preparing a patient for an invasive test with contrast media?
Any allergies to iodine
A 72-year-old patient has an indwelling it urinary catheter. Is sterile urine specimen has been ordered to the for culture and sensitivity. Which is the best method for the nurse to collect the urine specimen?
Aspirate 10 ML of urine with a syringe sterile from the tubing port
A nurse is caring for a client in the long term care facility who is receiving and enteral feedings via and NG tube. Which of the following is an appropriate nursing action prior to administering the two feedings?
Auscultate bowel sounds. Assisted client to an upright position. Test the pH of gastric aspirate
A patient with a urinary drainage system is a risk for infection. What intervention will help reduce the risk?
Avoiding placing drainage bag above the level of the catheter insertion
In the assessment of the patient's urine sample, what will the nurse consider and abnormal Finding?
Bloody mucus
The nurse is administering a routine and Enema to adult patient. The patient complains of cramping and the urge to defecate Which nursing intervention is best to carry out?
Briefly stop that instillation
The nurse is checking IV sides carefully for signs of infiltration
Burning sensation, pain, and puffiness at the site
Which skill can be delegated to staff other than licensed personnel?
Cold compress application
Which symptoms indicate fluid volume excess in an elderly patient?
Complains of shortness of breath and pounding pulse
What is consider it a noninvasive method of collecting urine for that incontinent patient
Condom catheterization
The nurse is instructing the patient in performing Kegel exercises The patient will be instructed to contract the muscles he or she will use to stop the flow of the urine. What is the proper teaching to perform Kegel exercises?
Contract for 10 seconds and relax for 10 seconds
What is culture sputum test?
Cultivation of microorganism or cells
A nurse is assessing the clients ability to learn self monitoring her blood glucose using vehicle meter. Which of the following ability to show the nurse confirmed that the client has before proceeding with teaching?
Finger dexterity Visual acuity Demonstration ability
A patient is receiving an IV infusion of blood. Once infusion has begun, what is the length of time the nurse should stay with the patient to monitor vital signs and watch for an allergic reaction?
First 15 to 20 minutes
What is sensitivity sputum test?
Determining effectiveness of antibiotics
The nurse is performing eye irrigation the nurse should perform which procedures?
Direct the irrigation fluid from the inner to the outer canthus
A client has an admission blood glucose reading of 260 MG per DL and no documented history of diabetes mellitus. While the nurse reviews the clients medication history, which of the following types of medication should alert the nurse to the possibility that the client has developed an advance effect of pharmacologic therapy
Diuretic (increased passing of urine.) Corticosteroids Antipsychotic
Mr. Kay has a nasogastric tube inserted. What type of patient teaching should the nurse give Mr. Kay about the NG tube
Don't pool at the tube
The nurse is caring for a patient with the new ostomy. What is the best nursing strategy for encouraging patient self-care on a ostomy?
Encourage the patient to watch the stoma care procedure? Gradually encourage participation
To maintain proper drainage over indwelling catheter? It is important to perform which actions?
Ensure that the connection device is below bladder level
A physician has ordered an aerobic culture from the patient's leg wound. Where on the wound will the nurse obtain this culture?
From the wound secretions
The nurse instructs the patient to be diligent in cleaning fecal matter from around the stoma because the fecal matter can cause which complications?
Fungal infection, bacterial infection, yeast infection, skin breakdown around the stoma
Aerobics organisms
Grows in superficial wounds exposed to the air
After inserting a nasogastric tube the nurse will check for proper placement by which method?
Gurgling or swishing sound heard with a stethoscope over this Dominic when air is injected into the tube 10 ML The ability to aspirate gastric contents with a syringe
A bladder training program for a patient in extended care facility should include which intervention?
Having the patient wear clothing protectors to help decrease embarrassment, put in the patient on q2 hour toilet scheduling during the day
What is the position for a NG tube insertion?
High Fowler's position
A nurse is teaching a client who just found out she has type one diabetes mellitus how to check her blood glucose level. Which of the following instructions to the nurse gave the client before transferring her blood into the Regent portion of the test strip?
Hold a test strip next to the blood on the fingertip
A nurse is teaching self monitoring of blood glucose SMBG to a client who has diabetes mellitus. Which of the following instructions should the nurse include?
Hold his hand in a dependent position prior to the puncture. Placed upon trying to buy is perpendicular to the site. Prick the outer edge of the finger tip for the blood sample.
The LVN is suctioning a patient throughout an endotracheal tube. What indicates proper technique?
Hyperventilating the patient before suctioning Deep in the suction catheter into sterile saline before suctioning Withdrawing the catheter without some covering the suction control vent
When a urine specimen is needed, how should the nurse instruct the staff to collect it?
Place a collection hat to the front of the toilet
The nurse is providing an informational session out of senior center I'm preventing constipation in older adults. Which information so the nurse include?
Increased activity, increase fluids, keep daily meal journal
What does black, Terry faces indicates?
Indicates the presence of old blood and that the side of bleeding is higher in the G.I. tract
An older adult is receiving IV therapy. The nurse knows this patient is at a greater risk for -----what are receiving this therapy
Infiltration
The nurse is assessing the IV site. If redness, swelling, and warm are noted, what is likely indicated.
Inflammation and possible phlebitis
What are fundamental requirements to protect patients rights
Informed consent the patient must fully understand what will be done during a test, surgery, or any medical procedure and must understand the risk and implications before he or she can legally consent to it
What does bright red blood indicate in the stool?
It indicates that the blood is fresh and the side of bleeding is in the lower gastrointestinal tract
A patient with a colostomy continues to worry about odor. Which statement will be appropriate for the nurse to tell the patient about colostomy odor
It is caused by certain foods that can be omitted from the diet
Diagnostic examination
It may be performed by physician at the patient's best side or in a special equipment room therapeutic or diagnostic procedures purpose
Which nursing intervention is most important in preventing the introduction of micro organism to the patient with an IV infusion is initiated?
Keep bag below level of the bed, provide Perenial care twice a day, coil tubing on the bed, keep the drainage system closed
The nurse is administering a cleansing Enema. Before administering the enema , the nurse assist the patient in which position?
Left Sam's position
A patient is scheduled for a barium enema study. Which instructions will be the patient is to follow?
Maintain NPO status after midnight before that examination Monitor bowel movements after the procedure. Increase fluid intake after the procedure.
The nurse is preparing a patient who is to receive a cleansing enema. The patient is assisted to which position?
Sims
A 64-year-old patient who has newly diagnosed diabetes has been learning how to perform her own blood glucose monitoring. What action can help to improve the specimen collection process?
Massage the hand prior to performing the specimen collection
What will the nurse do to determine the correct distance to insert a Nasogastric tube?
Measure from the tip of the nose to tip of the earlobe to the xiphoid
A sputum specimen has been ordered for a 75-year-old patient admitted with possible pneumonia of the right lower lobe. Which is the best method for the nurse to use with the patient who cannot expectorate sputum on he's or her own?
Nasotracheal suction
The healthcare provider has ordered a stool specimen for blood that is not possible to see with the naked eye. What does this examination detect?
Occult blood
If the patient is suspected of having a fecal impact which type of anemia with the nurse anticipate a healthcare provider to order?
Oil retention enema
Acid-fast bacillus
Organisms responsible for tuberculosis
What is true regarding a patient who receives oxygen via transtracheal method?
Oxygenation is usually achieve with less oxygen flow then with other systems
What is the next step perform by the nurse when a specimen has been obtained?
Properly identify it
When does the infusion nurses society INS suggest changing IV tubing on Perineal lines
Q 48 hours
Which nursing action is essential before a chest radiograph is obtain?
Remove the patient's metal necklace
What is the term for a urine specimen that is obtained by Catherization within 10 minutes after voids.
Residual urine specimen
A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse performed before beginning the procedure?
Review a signal the client can use if feelngany distress. Lay a towel across clients chest
A patient has been scheduled for an invasive diagnostic test. When writing my care plan which nursing diagnosis will be most appropriate?
Risk for anxiety related to diagnostic test/procedure
Cytology test?
Study of cells
When preparing a patient for an electrocardiogram ECG, which is the best position for the patient to be in?
Supine
When providing routine indwelling catheter care, the nurse should be most diligent in cleaning which areas?
The Perineal area and 2 inches of the catheter
A nursing student asked the nurse to explain the difference in a testing between a midstream urine specimen and a urinalysis. Which explanation will answer the nurse students question?
The midstream specimen is used to determine the culture and sensitivity of the urine specimen The midstream specimen is the cleanest portion of the urine specimen
It has been 15 minutes since a blood infusion was initiated. What is most indicated that the patient is experiencing a blood transfusion reaction?
The patient's blood pressure decreases
A patient performing a fingerstick for blood glucose determination ask why the side of the finger is advise as the preference site. Which is the best answer that the nurse will give the patient?
The side of the finger is less responsive to pain than other sites
A physician has ordered a sputum specimen to be collected on the patient. Which statement is appropriate teaching for the patient?
The sputum cannot contain any saliva
A patient is to obtain a stool sample at home for a hematest. Which teaching is most appropriate?
The stool specimen is not to be mixed with urine
What is the 24 hour urine specimen test for
This is required for test of renal function and urine composition
A 46-year-old patient is seen by the healthcare provider for recurrent symptoms of cystitis. The patient is to provide samples for urine culture and sensitivity. Which were the best answers the nurse can give to the patient went ask why the urine culture study has been ordered?
To identify the organism causing the infection
The nurses is assistanting to prepare a nursing care plan for a patient with continuous IV infusions. What is the goal of IV therapy
To promote and maintain fluid and electrolyte balance
Autologous blood transfusion
Using own blood intra
Bladder training instructions are being given to a patient who has a history of urinary incontinence. The should give the patient which instructions?
Void every 2 to 3 hours while you are awake
A nurse is developing an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asked the nurse why the water is necessary. Which of the following is appropriate response
Water helps clear the tube so it doesn't get clogged
A nurse at times to collect the capillary blood specimen via fingerstick to test the glucos level of a client who has diabetes mellitus. The nurse is unable to obtain an adequate drop of blood for the region strip, which of the following actions should the nurse take?
Wrap the clients hand in a warm, moist cloth
What is occult blood?
blood only seen under a microscope
A nurse is preparing to instill an enteral feeding to a client who has an NG tube in place. Which of the following is the nurse highest assessment priority before performing this procedure?
verify the placement of the NG tube
A central line is preferred over a peripheral IV line under which conditions?
when irrigation IV fluids are given. When the patient has poor peripheral veins, when the patient is to receive chemotherapy
