Fundamentals - Archer Review (3/3) - Skills/Procedures, Perioperative Care, Cultural, Spiritual, and Religion Concepts

Choice C is correct. Health care practitioners perform digital rectal exams (DRE) to check their aging male patients for benign prostatic hyperplasia (BPH) or prostate enlargement. Patients experiencing BPH may have difficulty starting a stream of urine or completely emptying their bladder.

A 63-year-old male is being seen in the clinic for his annual exam. Before performing a digital rectal exam. Which of the following questions should the nurse ask? A. "Are you exercising regularly?" B. "Has your diet changed dramatically in the past year?" C. "Have you had any difficulty starting a stream of urine when you attempt to use the toilet?" D. "Are you currently experiencing constipation?"

Choice C is correct. The wet dressing should not touch the intact skin as this may cause skin breakdown and potentially introduce additional pathogens into the wound.

A newly licensed registered nurse is tasked by a nurse educator to perform a wet-to-dry dressing change on a client with a stage 3 pressure ulcer. Which action would indicate to the nurse educator that the registered nurse is following proper technique? A. The registered nurse cleans the ulcer from the outside, rotating into the inside of the ulcer. B. The registered nurse packs the incision with sterile gauze, then pours sterile normal saline over the dressing. C. The registered nurse packs wet gauze into the ulcer without overlapping it onto the skin. D. The registered nurse saturates the old dressing with sterile saline before removing it.

- Educate the client on what is going to take place. Instruct client to relax and breathe normally while occluding one naris. Then repeat this action for the other nare. Select the nostril with greater airflow. - Determine the length of the tube to be inserted. Measure the distance from the tip of the nose to the earlobe to the xiphoid process (NEX) of the sternum. - Begin inserting the tube. Have the client relax and flex their head toward their chest after the tube has passed through the nasopharynx. - Encourage the client to swallow by taking small sips of water when possible. Then advance the tube as the client swallows. - Advance the tube each time the client swallows until you reach the desired length. - Temporarily anchor the tube to the nose with a small piece of tape. - Verify tube placement with a radiograph. Check agency policy for specific guidelines.

A nurse is caring for a client with a suspected bowel obstruction who requires a nasogastric (NG) tube insertion. Place the following steps in the correct order to insert an NG tube. Place the options below in the correct order that they should be performed. - Advance the tube each time the client swallows until you reach the desired length. - Educate the client on what is going to take place. Instruct client to relax and breathe normally while occluding one naris. Then repeat this action for the other nare. Select the nostril with greater airflow. - Begin inserting the tube. Have the client relax and flex their head toward their chest after the tube has passed through the nasopharynx. - Temporarily anchor the tube to the nose with a small piece of tape. - Determine the length of the tube to be inserted. Measure the distance from the tip of the nose to the earlobe to the xiphoid process (NEX) of the sternum. - Encourage the client to swallow by taking small sips of water when possible. Then advance the tube as the client swallows. - Verify tube placement with a radiograph. Check agency policy for specific guidelines.

Choice A is correct. Families consist of groups of emotionally connected individuals who function as a unit.

A nurse is precepting a new graduate nurse. They are working with a client with numerous family members at the bedside. Once they exit the room, the nurse asks the new graduate nurse to define "family." The new graduate nurse is correct when they state: A. "A family is a group of people who care about each other and work together to accomplish common goals or overcome hurdles." B. "A family includes a man and a woman who are married and the children they have together." C. "In order to be considered family, you have to be related through blood, marriage, or adoption." D. "Although there may be extended family elsewhere, the people who live in someone's house are their family members."

Choice D is correct. For Jehovah's Witnesses, surgery is allowed, but the administration of blood and blood products is forbidden.

A nurse is preparing the plan of care for a client with stage 2 ovarian cancer who is a Jehovah's Witness. The client has been told that surgery is necessary. After discussing the client's religious preferences with the client, the nurse documents which of the following while creating the care plan? A. Religious sacraments and traditions are unimportant B. Medication administration is not allowed for this client C. Surgery is strictly prohibited for this client D. Administration of blood or blood products is not allowed for this client based on religious beliefs

Choice D is correct. Iodinated contrast materials are used during cerebral angiography, potentially causing severe allergic reactions. Here, the client's itchy throat and watery eyes are classic indications of an allergic reaction that may progress to an anaphylactic reaction. Symptoms of a severe anaphylactic reaction include airway compromise due to laryngeal edema or angioedema(stridor), bronchoconstriction (wheezing, cough, and dyspnea), and/or circulatory collapse (shock). This is an extreme emergency, as the client's airway is at risk of compromise. The nurse should promptly assess the client for additional signs of anaphylaxis, notify the health care provider (HCP), and initiate interventions to stop further symptom progression while alleviating the current manifestations.

A nurse is taking care of a client undergoing cerebral angiography. Which statement by the client would most warrant additional attention from the nurse? A. "I feel like I'm going to vomit." B. "I hope my results are okay." C. "It's getting a bit hot in here." D. "My throat is getting a bit itchy, and my eyes are getting watery."

Choice B is correct. Patent vascular access of at least a 20-gauge catheter is necessary before the infusion of intravenous contrast. Extravasation of contrast media can be severe, and treatment involves stopping the infusion, removing the catheter, and elevating the extremity above the heart. This can be avoided by establishing IV patency before the infusion of contrast. Warm or cold compresses may also be helpful.

A nurse prepares a client for computed tomography (CT) scan with intravenous (IV) iodinated contrast. The nurse should take which action? A. Ask the client if they are allergic to shellfish B. Insert a 20-gauge peripheral vascular access device C. Obtain capillary blood glucose (CBG) D. Instruct the client to decrease their fluids after the procedure

further deflate the catheter balloon

Drag words from the choices below to fill the blank in the following sentence Prior to attempting to remove the catheter again, the nurse should _____

Choice D is correct. Autologous donations are not screened for infectious diseases. According to the Food and Drug Administration (FDA), autologous donations are not screened because autologous donors are not exposed to new transfusion-transmitted infections in receiving their own blood.

Following a detailed conversation between a nurse and a client regarding autologous blood donations, which of the following statements, if made by the client, would indicate the need for additional education on the topic? A. "Autologous donations require a health care provider's (HCP) order." B. "There is no age limitation for autologous blood donations." C. "I can begin autologous blood donations five weeks before my surgery date and continue up until 72 hours before surgery." D. "My autologous blood donation will be screened for infectious diseases."

Choice D is correct. Scientific health beliefs are grounded in scientific research and evidence-based practice. With research and science, we can know the etiology of diseases and also ways to treat illnesses/disorders. Therefore the clients' compliance and adherence to the medical regimen are essential to health and recovery.

Select the classification of cultural beliefs/practices that are accurately paired with an example of it. A. Holistic health beliefs: A pathogen causes infection and this leads to health problems. B. Magical health beliefs: Illness results from disharmony of the body and the mind. C. Scientific health beliefs: The wearing of an amulet to protect health. D. Scientific health beliefs: Compliance with the medical regimen is essential to health.

Choice A is correct. Preoperative antibiotics are prescribed and administered before surgery to reduce surgical site infections (SSI). Orthopedic surgery, such as spinal surgery, is common in which a preoperative antibiotic is indicated. Preoperative antibiotics are given within sixty minutes of the surgical incision and may be continued to be given up until 24 hours after surgery.

The nurse cares for a client scheduled for spinal surgery in one hour. The nurse anticipates that the primary healthcare provider (PHCP) will prescribe A. gentamicin. B. enoxaparin. C. hydromorphone. D. cyclobenzaprine.

Choice A is correct. Getting chest and abdominal x-rays are the gold standard to verify that the enteral tube placement is correct.

The med-surge nurse is caring for a patient who is receiving enteral feedings. What is the most effective method to verify initial tube placement is correct? A. Obtain chest and abdominal x-rays. B. Aspirate the contents to assess pH range. C. Mark tubing at the exit site and record the length of tubing that protrudes. D. Insert 20-30 mL of air into the tube while auscultating the epigastrium.

Choice C is correct. One of the fundamental aspects required when following a kosher diet is avoiding consuming meat and dairy products during the meal. Offering the client sweet and sour chicken with rice and vegetables, assorted fruits, sweet tea, and iced water is acceptable, as the meal does not violate any kosher dietary laws. In the kosher diet, certain poultry is allowed, such as chicken, goose, duck, and turkey, but all others are forbidden.

The nurse assists a client in picking out items on the menu that are permitted in the kosher diet. Which of the following dietary items would be allowed? A. Pork belly roast, rice, vegetables, mixed fruit, 2% milk, iced water B. Crab salad on a croissant, potato salad, vegetables with dip, 2% milk, iced water C. Sweet and sour chicken with rice and vegetables, assorted fruits, sweet tea, iced water D. Fettuccini alfredo with shrimp and vegetables, salad, mixed fruit, sweet tea, iced water

Choice B is correct. Assessing the client's oxygen saturation is essential because this client is demonstrating manifestations of hypoxia. Early signs of hypoxia include altered mental status and restlessness. Moderate sedation uses multiple medications, such as fentanyl and propofol, to achieve a state of altered consciousness, so procedures like shoulder reductions may be completed with very little pain. These medications are CNS depressants, and during the procedure, the client is often given supplemental oxygen. Post-procedurally, the nurse will monitor the client's vital signs very closely.

The nurse cares for a client immediately following a shoulder reduction procedure with moderate sedation. The nurse assesses the client as restless and irritable. The nurse should take which priority action? A. Assess the client for pain B. Assess the client's oxygen saturation C. Assess the client with the Glasgow Coma Scale (GCS) D. Assess the client's lung sounds

Choice D is correct. Ensuring that the PICC line is patent is essential. This is accomplished by aspirating each lumen for blood return and then flushing each with saline. This measure will help in preventing occlusion.

The nurse cares for a client who has a double-lumen peripherally inserted central catheter (PICC). Which of the following actions would be appropriate for the nurse to take? A. Assign the client to a private room. B. Change the dressing daily using sterile technique. C. Flush heparin prior to discontinuation. D. Aspirate each lumen for blood return and then flush.

Choice C is correct. This statement requires follow-up because clients should be lifted into position instead of sliding. Sliding may cause friction and shearingskin injuries. The older adult is more prone to skin injuries because of the decreased dermal and epidemial blood flow and dryness of the skin.

The nurse has attended a conference on intraoperative nursing interventions for the older adult. Which of the following statements by the nurse would indicate the need for additional teaching? A. "Warming devices should be used to prevent the client from developing hypothermia." B. "The client's head and feet should be covered during surgery." C. "Clients should be slid, not lifted into the proper position." D. "Providing extra padding for clients with decreased peripheral circulation is important."

Choices A and B are correct. Alternative medical choices and natural treatments are commonly used in this culture. The nurse should recognize this fact because standard therapies may be abandoned for treatments that may be unproven. Church and religion are fundamental in this community. If an individual in the community is ill, it is common for a religious leader to request updates about the client's condition.

The nurse has attended a staff conference on cultural considerations. Which of the following statements would be correct regarding the Amish culture? Select all that apply. - Natural and alternative treatments are common in the community - Church is extremely important in this community - Women and men are equal and can both make healthcare decisions - Most of the Amish community choose to have health insurance - Blood and blood products are commonly declined

Choice B is correct. A Kock pouch is an internal urinary reservoir made from the terminal ileum. This is created during the continent urinary diversion (continent urostomy) procedure. The urine diverts to and gets stored in the pouch. Postoperatively, the client will have an indwelling urinary catheter to drain urine continuously until the pouch has healed. This catheter will require irrigation. Clients will then perform self-catheterization every 4 to 6 hours to empty this internal pouch and for urinary diversion.

The nurse identifies that one of her clients will need education on caring for their stoma and instruction on self-catheterization by three weeks post-op. Based on this information, what urinary diversion methods does this client have? A. Vesicostomy B. Kock Pouch C. Ileal Conduit D. Condom Catheter

Choice A is correct. High-pitched crowing sounds are consistent with a client having stridor. Stridor is a concerning adventitious breath sound because it indicates upper airway narrowing. The nurse needs to immediately respond to this client and determine if they have anaphylaxis to an intraoperative medication or a mechanical obstruction.

The nurse in the postanesthesia care unit (PACU) cares for a client who had an appendectomy. Which of the following client assessments warrants immediate follow-up? The client A. has breath sounds that are high-pitched and crowing. B. reports incisional pain at a level of '5' on a scale of 0 (no pain) to 10 (severe pain). C. has a capillary blood glucose of 115 mg/dL [70-110 mg/dL]. D. reports persistent nausea following the administration of an anti-emetic.

Choice A is correct. A significant risk following bariatric surgery is venous thromboembolism. The nurse should be aware of this serious complication and implement preventative measures such as administering prescribed anticoagulants, encouraging ambulation, and leg exercises while the client is in bed.

The nurse is assessing a client who had gastric bypass surgery two days ago. The nurse should prioritize assessing the client for A. venous thromboembolism. B. their current weight. C. nausea and vomiting. D. surgical site infection.

Choice A is correct. The client's 10:30 AM vital signs show signs of shock. Considering this client is in the immediate postoperative period, the nurse should assess the surgical wound for signs of hemorrhage. The nurse should reinforce the dressing if this is the source of the bleeding. The nurse should notify the primary healthcare physician (PHCP) of the client's change in condition.

The nurse is assessing a client who just returned from surgery. The nurse checks preoperative vital signs at 8:30 AM to compare them with the current vital signs at 10:30 AM. What action should the nurse take? See the image below. A. Assess the surgical wound B. Collect blood cultures C. Administer oxygen at 2 L/minute D. Encourage by-mouth (PO) fluids

Choice D is correct. It is appropriate to allow the child and the mother to unwrap the eating utensils. This is the only action listed that allows the child and the mother to remain kosher as requested.

The nurse is caring for a 5-year-old client whose family is of Orthodox Jewish faith. The mother requests that the client remains kosher while in the hospital. Which of the following actions while assisting the child with lunch would best respect the mother's request? A. Finding metal utensils instead of plastic B. Placing the food on plastic plates instead of paper C. Helping the child unwrap the plastic utensils from their packaging D. Allowing the child and his mother to unwrap the eating utensils

Choice A is correct. A myringotomy is a procedure performed to facilitate drainage from the eardrum. This is often performed to relieve pressure and pain with acute otitis media. Tympanostomy tubes may be placed to remove exudate and equalize the middle ear and atmospheric pressures. Following this procedure, the child should be placed on the affected side to facilitate drainage via gravity.

The nurse is caring for a child immediately postoperative following a left ear myringotomy. The nurse should position the child A. left lateral recumbent. B. prone. C. right lateral recumbent. D. modified trendelenburg.

Choice D is correct. A client with severe pre-eclampsia should be monitored closely for seizures which are the hallmark manifestation of eclampsia. The nurse should plan care involving seizure precautions at the bedside, including suction equipment, padded side rails, and oxygen.

The nurse is caring for a client admitted with severe pre-eclampsia. It would be essential for the nurse to have which of the following items at the bedside? A. One liter of 0.9% saline B. Sterile gloves C. Portable ultrasound D. Suction equipment

Choice B is correct. After a thyroidectomy, the nurse is concerned about the client developing hypocalcemia. Hypocalcemia may occur because of the devascularization of the parathyroid, which regulates calcium. It is routine for clients recovering from a thyroidectomy to receive prescribed calcium carbonate. The nurse must surveil the client for severe manifestations of hypocalcemia, which include tetany, numbness, tingling around the mouth, and muscle twitching.

The nurse is caring for a client eight hours following a total thyroidectomy. The nurse plans obtaining an order to assess the client's serum A. potassium level. B. calcium level. C. sodium level. D. glucose level.

Choice C is correct. Hypophysectomy is generally performed via the transsphenoidal route to remove tumors from the pituitary gland. Semi-Fowler's to Fowler's position is the most appropriate as it facilitates drainage.

The nurse is caring for a client immediately following hypophysectomy. The nurse should position the client A. Trendelenburg B. Side-lying C. high-Fowler's D. Reverse Trendelenburg

Choices B, D, E, and F are correct. Choice B is correct. The nurse should always approach the client from the unaffected side. Here, the nurse would approach this client from the client's left side to avoid startling the client. Choice D is correct. Activities that increase intraocular pressure, such as bending down, should be avoided. Choice E is correct. The client should always be oriented to their environment to prevent unwarranted injury. Choice F is correct. A prescription for a stool softener is provided for multiple reasons. First, activities that increase intraocular pressure should be avoided. Since constipation and straining during defecation often increase intraocular pressure, stool softeners are administered to prevent constipation prophylactically. Second, any use of opioid pain medication during the surgical or postoperative procedure would likely inhibit gastrointestinal and colonic motility. A stool softener would assist in alleviating this medication side effect.

The nurse is caring for a client immediately following scleral buckling surgery for a retinal detachment of the right eye. Which of the following actions would be appropriate for the nurse to take? Select all that apply. - place the client in a prone position. - approach the client from the left side. - instruct the client to perform deep -breathing and coughing exercises. - instruct client to avoid bending down. - orientate the client to the environment. - obtain a prescription for a stool softener.

Pulse (P) 94 bpm 104 bpm Blood pressure (BP) 101/63 mm Hg 91/58 mm Hg Oxygen saturation 95% Room Air 93% Room Air

The nurse is caring for a client immediately post-operative following an open ventral hernia repair The nurse reviews the 1230 and 1300 vital signs Click to highlight the 1300 vital sign(s) that would require follow-up Vital Sign. 1230. 1300 Pulse (P) 94 bpm 104 bpm Respirations (R) 18/min 19/min Blood pressure (BP) 101/63 mm Hg 91/58 mm Hg Temperature (T) 98°F (36.7°C) 97.5°F (36.3°C) Oxygen saturation 95% Room Air 93% Room Air

Choice B is correct. A complication following an amputation is hemorrhage. An early assessment and action of the nurse is to monitor the client for hemorrhage, which may be evident on the bandage, or if the client has a drain, a large amount of bloody drainage may be apparent. Findings that may support that the client is hemorrhaging include tachycardia with later development of hypotension. Rather the amputation is traumatic or surgically performed; it is hemorrhage that is a concerning complication.

The nurse is caring for a client immediately postoperative following a below-the-knee amputation. The nurse should take which priority action? A. Elevate the stump on a pillow B. Check the operative site for bleeding C. Obtain an order for a physical therapy order D. Demonstrate the use of incentive spirometry (IS)

Choice D is correct. This client is displaying classic signs and symptoms of hypocalcemia (i.e., paresthesia and tetany). If left untreated, symptoms may progress to seizures, encephalopathy, and heart failure. More convincingly, the client's recent thyroidectomy supports a presumptive diagnosis of hypocalcemia. Although the thyroid gland in and of itself does not regulate calcium levels within the body, four parathyroid glands (responsible for releasing parathyroid hormone (PTH) to control calcium levels in your blood) are located within the thyroid. Hypoparathyroidism often results after the accidental removal of or damage to one or more parathyroid glands during thyroidectomy. The nurse should anticipate administering intravenous calcium gluconate (or chloride) to this client.

The nurse is caring for a client seven hours postoperative following a subtotal thyroidectomy. The client reports peripheral numbness and tingling, muscle twitching, and spasms.The nurse anticipates a prescription for A. levothyroxine. B. hydrocortisone. C. thiamine. D. calcium chloride.

Choices A, B, D, and E are correct. This client data reflects that the client is ready for discharge home. The client has a positive gag reflex, adequate urinary output (UOP) for the postoperative time frame (> 30 mL/hr), positive bowel sounds, and minimal pain. The client's UOP is high, but it would only be concerning if it were low. Intraoperative IV fluids may be given to explain the surgery that explains the increased UOP. Hypoactive bowel sounds immediately following anesthesia is expected because anesthesia decreases peristalsis. Absent bowel sounds would be a concerning finding. The client's pain is minimal and does not inhibit their ability to be discharged. Colonic motility is typically restored within 72 hours following surgery.

The nurse is caring for a client three hours postoperative following a laparoscopic appendectomy. Which of the following client data indicates the client is ready for discharge home? Select all that apply. Positive gag reflex Hypoactive bowel sounds Blood pressure 90/60 mm Hg Incisional pain '2' on a scale of 0 to 10 Urinary output of 240 mL since surgery

Choice B is correct. The client's blood pressure and pulse have steadily increased. Manifestations of poor pain control include sympathetic responses, which cause an increase in blood pressure and pulse. Other nonverbal manifestations include pupil dilation, sweating, guarding of the surgical wound (or affected area), and social withdrawal.

The nurse is caring for a client two days post-operative following gastroduodenostomy. After reviewing the clinical data, the nurse should take which action? See the exhibit. View Exhibit A. obtain a prescription for an antihypertensive B. determine if the client's pain is being controlled C. assess the client's surgical wound for signs of infection D. notify the physician for concerns of hypovolemic shock

Choice C is correct. Immediately postoperative clients run the risk of airway, breathing, and circulation compromise. Surgeries often result in a client losing volume and may cause intraoperative and postoperative bleeding. The nurse must be aware that an increased heart rate and low blood pressure are classic indicators of fluid volume deficit, which, if untreated, may cause the client to develop hypovolemic shock. Hypovolemic shock may be caused by hemorrhage, a significant concern immediately post-operative.

The nurse is caring for a client who is immediately postoperative following a colon resection with the placement of a colostomy. Which of the following client problems are of greatest concern? A. Infection B. Thermoregulation C. Hemorrhage D. Altered body image

Choice D is correct. Glipizide is a sulfonylurea and is given to the client with meals to manage blood glucose. This medication will lower blood glucose and could potentially cause hypoglycemia. The client is NPO and will not receive any food. Thus, the nurse should question the administration of this medication to prevent the client from developing hypoglycemia.

The nurse is caring for a client who is nothing by mouth status (NPO) for scheduled surgery. Which prescribed medication requires clarification with the physician prior to administration? A. metoprolol B. phenytoin C. levothyroxine D. glipizide

Choice B is correct. In Islamic tradition, it is customary to position the deceased person's body facing the holy city of Mecca during the preparation for burial. This is an important religious practice, as Mecca is considered the holiest city in Islam. Mecca is located in western Saudi Arabia. The specific direction to Mecca varies depending on the geographical location of the observer.

The nurse is caring for a client who is of the Islamic faith, who has expired. The nurse should take which appropriate action? A. Prepare the client for cremation B. Position the client facing Mecca C. Keep the client's eyelids open D. Keep the client uncovered

Choice C is correct. Hypostatic pneumonia after surgery is best prevented through incentive spirometry and early mobilization. The purpose of incentive spirometry (IS) is to promote deep breathing to prevent or treat atelectasis in the postoperative client. Hypostatic pneumonia is caused by pulmonary congestion in the dorsal region of the lungs. This type of pneumonia is common for those who are bedridden or have restricted mobility. Hypostatic pneumonia can be prevented through early postoperative ambulation and incentive spirometry.

The nurse is caring for a client who is postoperative ordered incentive spirometry. The nurse understands that this device will help prevent which complication? A. venous thromboembolism B. obstructive sleep apnea C. hypostatic pneumonia D. aspiration pneumonia

Choices A, C, D, and E are correct. A client experiencing acute pain will have activation of the sympathetic nervous system, therefore, causing signs and symptoms such as: Nausea, vomiting Diaphoresis Increased pulse Tachypnea Increased blood glucose Increased blood pressure Dilated pupils (mydriasis)

The nurse is caring for a client who is recovering from surgery. Which assessment data would suggest that the client's pain is not well controlled? Select all that apply. Tachypnea Bradycardia Nausea Mydriasis Increased blood glucose

Choice B is correct. Most Jehovah's Witnesses do not condone the use of blood products and often refuse blood transfusions. Witnesses believe that voluntarily accepting blood transfusion may affect their eternal salvation, and the aversion comes from interpreting a Biblical scripture. This nurse should verify this information in the chart and with the client, as exceptions with religions and cultures exist.

The nurse is caring for a client who may require a prescribed blood transfusion. The nurse understands which of the following cultural groups prohibit blood transfusions? A. Catholicism B. Jehovah's witnesses C. Islam D. Christian reform

Choice A is correct. The client's post-procedure blood pressure is highly concerning as it reflects clinical hypotension. Medications used in moderate sedation have a vasodilating effect, and the nurse should intervene to increase the client's blood pressure via prescribed intravenous (IV) fluids.

The nurse is caring for a client who underwent moderate sedation for a closed shoulder reduction. The nurse reviews the client's clinical data. Which post-procedure data requires immediate follow-up? See the image below. A. Blood Pressure B. Glasgow Coma Scale C. Respirations D. Temperature

Choice B is correct. Scissors must be kept at the bedside of any client with a Sengstaken-Blakemore tube. The nurse should check for this essential item at the beginning of the shift to ensure the safety of the client. A Sengstaken-Blakemore tube has esophageal and gastric balloons. If the gastric balloon ruptures or moves substantially, the entire tube might migrate proximally, resulting in airway obstruction. This is an emergency, and the nurse must act immediately to deflate the balloons. Scissors are always kept at the bedside to cut across all the tube lumens and rapidly deflate the balloons. Following this, the tube can be extracted.

The nurse is caring for a client with a Sengstaken-Blakemore tube. The nurse performs safety checks at the beginning of the shift and ensures which priority item is readily available at the bedside? A. Trach kit B. Scissors C. Obturator D. Yankauer suctioning

Choices A, B, D, and E are correct. A port is a central venous line that is useful for individuals receiving chemotherapy. The nurse should utilize an aseptic technique to prevent central line-associated bloodstream infections (CLABSIs) when the port is accessed. This includes the nurse and the client wearing a mask as well as the nurse using sterile gloves. Occlusion is a common complication with a port, and prior to de-accessing, the nurse should flush heparin. Further, the client should be instructed to wear a mask to prevent contamination during dressing changes. Finally, the nurse must verify appropriate access by aspirating for blood return prior to medication administration.

The nurse is caring for a client with a port. Which of the following actions would be appropriate to take? Select all that apply. - Access the port using sterile technique. - Flush the port with heparin prior to de-access. - Access the port using a 16-gauge catheter. - Have the client wear a mask during the dressing change. - Aspirate for blood return prior to medication administration.

Choice B is correct. An inner cannula of the tracheostomy size and one smaller must be kept at the bedside. This is essential in case the existing inner cannula becomes dislodged.

The nurse is caring for a client with a tracheostomy. Which of the following items is essential to have at the bedside? A. Air humidifier B. Inner cannula C. Nasal cannula oxygen D. Tracheostomy brush

Choice D is correct. Stridor indicates respiratory distress and should be immediately reported to the health care provider. Stridor sounds high-pitched and coarse, it is usually heard with the stethoscope over the trachea.

The nurse is caring for a patient who has had an endotracheal tube removed within the last hour. What sign if noticed in the patient, should be reported to the primary care physician immediately? A. Slightly pink sputum B. A hoarse voice or sore throat C. Respiratory rate of 22 D. Stridor

Choice C is correct. Patients who have undergone a femoral vein catheter should refrain from sitting up more than 45 degrees because this could kink the catheter, thus interfering with treatment.

The nurse is caring for a patient who has recently had a femoral vein catheter placed. The nurse would be most correct in advising the patient to do which of the following? A. Refrain from drinking more than 500 mL per day B. Perform toe touch stretches in bed every morning C. Refrain from sitting up more than 45 degrees D. Remove the dressing if it becomes itchy

Choice C is correct. Early ambulation is beneficial because it prevents venous thromboembolism (VTE) and respiratory complications such as hypostatic pneumonia. Ambulation increases ventilation and mobilizes secretions, both of which help prevent the development of pneumonia.

The nurse is caring for a post-operative client at high risk for pneumonia. Which intervention would be most effective in the prevention of this complication? A. Passive range of motion B. Sequential compression devices (SCDs) C. Early ambulation D. Prophylactic antibiotics

Choice D is correct. High-protein foods are encouraged because they promote wound healing and prevent fluid shifting, which may lead to a pressure ulcer. The prevention of fluid shifting (edema) contributes to a pressure ulcer. Optimal protein intake is key to preventing (and healing) a pressure ulcer.

The nurse is caring for a post-operative client at risk for a pressure ulcer. Which intervention should the nurse include in the plan of care? A. Apply sequential compression devices B. Apply an extra sheet to the bed C. Position the client on a donut pillow D. Encourage the consumption of high-protein foods

Choice D is correct. A bowel prep will cause the client to ambulate to the bathroom frequently. The client is an older adult, and being an older adult is a risk factor for falls. The nurse should consider using a bedside commode to shorten the ambulation distance, mitigating the fall risk.

The nurse is caring for an older adult client undergoing bowel prep for a scheduled colonoscopy. Which nursing diagnosis is the priority to integrate into the care plan? A. Deficient knowledge B. Altered elimination pattern C. Impaired skin integrity D. Risk for falls

Choices B and E are correct. The client following surgery is at high risk for venous thromboembolism (VTE). Considering that this client is older and had a musculoskeletal procedure, this significantly increases the risk for postoperative VTE. Thus, anticoagulants such as heparin or enoxaparin are prescribed to prevent this complication. Following this surgery, the older adult may experience pain treated with opioids or non-opioids. Morphine is an opioid medication that may be given orally or parenterally to provide pain control. The nurse should assess the client's blood pressure and respirations before administering morphine because morphine may cause respiratory depression and hypotension.

The nurse is caring for an older adult following a total hip arthroplasty. The nurse should anticipate a prescription for which postoperative medication? Select all that apply. Hydrocortisone Enoxaparin Metoprolol Furosemide Morphine

Choice C is correct. Acculturation is the process by which members of another culture learn and adopt the dominant culture. For example, this could occur when a client begins celebrating a new holiday that they did not observe before. Although acculturation and assimilation are similar, adaptation is the process by which a person develops a new cultural identity rather than assimilating and adopting a new culture while retaining their own.

The nurse is conducting a class regarding cultural competency. It would indicate effective understanding if the student states that when a client is learning the beliefs, values, and practices of their new cultural setting, this demonstrates A. immigration. B. emigration. C. acculturation. D. cultural awareness.

Choice C is correct. A transillumination device may be of benefit to you when you are having difficulty locating a vein for this venipuncture and have to begin an intravenous therapy line for a client who is dark-skinned. Transillumination devices light up the area, and this light is sufficient to locate veins regardless of the client's skin color. These devices are also capable of identifying veins that are not palpable or visible when the client is obese.

The nurse is having difficulty locating a vein, to start intravenous therapy, on a client who is dark-skinned. Which of these devices or procedures may be of benefit to you at this time? A. A doppler B. A surgical vein cut down C. A transillumination device D. A sonography

Choice C is correct. The nurse should inflate the balloon on the catheter at the bifurcation point. The nurse should advance the catheter until urine flows out of the catheter. When urine appears in the indwelling catheter, the nurse should move it to bifurcation. The nurse will do this to ensure that the balloon part of the catheter is not still in the prostatic urethra. The bifurcation of the catheter is the "Y" junction where the balloon arm and catheter meet. After the nurse inflates the catheter balloon, gently pull the catheter until resistance is felt. Then, advance the catheter slightly. This is done to prevent pressure on the bladder neck.

The nurse is inserting an indwelling urinary catheter in a male client. It would be appropriate for the nurse to inflate the catheter's balloon when A. meeting resistance. B. as soon as urine is observed in the tubing. C. after advancing to the point of bifurcation. D. after fully advancing the length of the catheter.

Choice A is correct. This observation requires follow-up because it will likely enter the respiratory tract if the nasogastric tube ( NGT) is advanced as the client takes a breath. The preferred method is gently advancing the NGT each time the client swallows until the desired length is reached. One can feel the characteristic tug on the tube as the epiglottis closes during swallowing. During the advancement of the tube, if the client begins coughing or becomes cyanotic, the nurse should pull the tube back until the client breathes normally again. Cyanosis and severe coughing during tube insertion can indicate accidental positioning of the tube in the respiratory tract ( trachea and bronchi).

The nurse is observing a newly hired nurse insert a nasogastric tube (NGT). Which action by the newly hired nurse requires follow-up? A. Advances the tube during the client's inspiration. B. Hands the client a cup of water and straw. C. Positions the client's head-of-bed at 90 degrees. D. Washes the client's bridge of nose with soap and water.

- Ask the client to void - Position the client supine with the knees bent and the arms at their side - Place pillows beneath the client's knees - Inspect the abdomen - Auscultate all four quadrants of the abdomen - Palpate the abdomen

The nurse is performing a focused physical assessment. Place the steps in correct order to perform a gastrointestinal assessment. Place the steps in the appropriate order. - Position the client supine with the knees bent and the arms at their side - Inspect the abdomen - Auscultate all four quadrants of the abdomen - Ask the client to void - Palpate the abdomen - Place pillows beneath the client's knees

Choice D is correct. For the abdominal exam, the exact sequence of actions would be inspection, auscultation, percussion, and palpation. The abdominal assessment is an integral part of the evaluation of any patient, but it is critical when the chief complaint is related to intestinal issues. The abdominal assessment should always progress from least intrusive (inspection) to most invasive. All findings should be related to one or more of the four quadrants of the abdomen. For example, a laceration noted in the right upper quadrant might be a documented finding. During the abdominal assessment, the clinician should look at the stomach first, observing for swelling, lacerations or punctures, asymmetry, or other abnormalities. In the second step, auscultation, the clinician is listening for bowel sounds. It is essential to do this before palpation or percussion since any manipulation of the abdomen can change the bowel sounds. If bowel sounds are not immediately auscultated, the clinician should spend 30-60 seconds listening. Palpation should be gentle to determine the amount of discomfort the patient is having. When percussion is needed, it helps the nurse assess the borders of the major o

The nurse is performing a head-to-toe assessment of the patient. During the abdominal evaluation, the correct sequence for this assessment is: A. Auscultation, Inspection, Palpation, Percussion B. Inspection, Palpation, Auscultation, Percussion C. Percussion, Auscultation, Palpation, Inspection D. Inspection, Auscultation, Percussion, Palpation

Choice B is correct. Clients with ascites present with tightly stretched skin over a rounded, distended abdomen due to accumulation of fluid in the peritoneal cavity typically related to liver disease, portal hypertension, tuberculosis, or nephritic syndrome. Upon percussion of the abdomen, the nurse would expect to note tympany over the top of the abdomen where the intestines float. and dullness over the sides where fluid settles (fluid shifts when the patient is turned to the side).

The nurse is performing a physical assessment on a client with ascites. While the client is positioned supine, the nurse should percuss for tympany A. on the sides of the abdomen. B. over the umbilicus. C. below the umbilicus. D. over each flank area.

Choice C is correct. Pack-years are calculated by multiplying the number of packs smoked per day by the years the client has smoked. Pack-years (PY) = number of packs of cigarettes per day (P) x number of years of smoking (Y) In this client, twelve is the correct amount of pack-years. The client has smoked two packs of cigarettes for six years (PY = two packs x six years = twelve pack-years).

The nurse is performing community health screenings. A client tells the nurse that they smoke two packs a day of cigarettes and have smoked for six years. The nurse should document this finding as how many pack years? A. 3.5 pack years B. 3 pack years C. 12 pack years D. 6 pack years

Choice D is correct. Daily cleaning of the urinary meatus with soap and water is recommended for catheter care. Sterile gloves do not need to be used for this process as it is a clean procedure. Soap and water is an acceptable practice for daily catheter care as alcohol, CHG, and other antiseptics may be highly irritating to the urinary meatus.

The nurse is planning a staff educational conference about indwelling urinary catheters. Which of the following information should the nurse include? A. Sterile gloves should be used to perform urinary catheter care. B. Urinary specimens may be collected from a catheter bag. C. You may irrigate a catheter with warm water for poor outflow. D. Daily use of soap and water should be used around the urinary meatus.

Choice A is correct. The most accurate definition of the family is a unit comprised of members who can be related or not related and bound legally or in a nonlegal manner.

The nurse is precepting a new graduate nurse. They are working with a client who has many family members present at the bedside. The nurse knows family dynamics are an important component of management of care, and asks the new graduate to define family. The new graduate nurse is correct when they state: A. A unit comprised of members who are related or not related. B. A unit comprised of blood-related relatives. C. A dyad of a male and female. D. A dyad of heterogeneous or homogeneous genders.

Choice D is correct. A pillow should also be placed under the client's shoulder on the side that is being assessed. Breast inspection and palpation should be performed on both men and women. The client can be sitting or lying supine. The client should sit erect with arms at the sides or raised overhead. When flat, the client's hand on the examined side is placed under the head, if possible. Examination of the breast and axilla are often performed sequentially with the assessment of the thorax, lungs, and heart.

The nurse is preparing a client for a breast exam. The nurse should position the client A. supine with arms at the side and a pillow under both knees. B. left lateral with the head resting on a pillow and the arm over the head. C. sitting forward with a pillow behind the shoulder blades with hands on the hips. D. supine, with the arm on the side examined behind the head and a small pillow under the shoulder.

Choice C is correct. Tranexamic acid causes inhibition of fibrinolysis. Thus, it helps reduce blood loss for specific operative procedures and trauma. Orthopedic procedures such as hip arthroplasty cause significant intraoperative and postoperative blood loss. This could cause the client to receive a postoperative blood transfusion. This medication is administered intravenously approximately 30 minutes before the operative procedure.

The nurse is preparing a client scheduled for hip arthroplasty in two hours. The nurse has received a prescription for tranexamic acid. The nurse understands that this medication has had a therapeutic effect when the client has A. decreased postoperative pain. B. increased postoperative vital capacity. C. less postoperative blood loss. D. no surgical site infection.

Choices A, B, C, and E are correct. Moderate sedation is utilized for closed reduction procedures, which involves placing the bone back in alignment without making an incision into the skin. Moderate sedation for a closed reduction of a shoulder is quick, and pain is minimal with the use of moderate sedation. Midazolam, fentanyl, or propofol is commonly used for moderate sedation. The nurse must carefully watch the client's vital signs, end-tidal carbon dioxide, and cardiac rhythm during the procedure.

The nurse is preparing for a client to undergo a closed reduction of the shoulder with moderate (procedural) sedation. The nurse plans on obtaining which clinical data during the procedure? Select all that apply. Blood pressure End-tidal carbon dioxide [ETCO2] level Respiratory rate Blood glucose Oxygen saturation

Choice C is correct. Following a lumbar spinal fusion, the client will need to be log rolled. A transfer board/sheet, along with an ample amount of staff (at least three), will be necessary to facilitate the log roll.

The nurse is preparing to admit a client following lumbar spinal fusion surgery. The nurse should instruct the unlicensed assistive personnel (UAP) to have which equipment at the bedside? A. Overhead trapeze B. Abduction pillow C. Transfer board D. Continuous passive motion (CPM)

Choice B is correct. This positioning is appropriate when placing an NGT. Placing the client in this position promotes the client's ability to swallow during the procedure. The nurse should place the pillow behind the client's shoulder blades to allow the client to flex and extend their neck.

The nurse is preparing to insert a nasogastric tube (NGT) for a client with abdominal distention. The nurse should place the client in which position for this procedure? A. Supine with the head of the bed elevated at 30 degrees B. Supine with the head of the bed 90 degrees C. Left-lateral position with the knees bent D. Right-lateral position with the knees bent

Choice A is correct. Cleaning the wound with sterile normal salineimmediately before obtaining a wound culture is appropriate. One of the concerns during specimen collection is that contamination with skin flora may render the culture result inaccurate. Therefore, cleansing with sterile saline will ensure no residual skin flora is sent with the sample. The nurse should never collect a wound culture sample from old drainage.

The nurse is preparing to obtain a wound culture on an infected leg ulcer. Before swabbing the wound to obtain the culture, the nurse should A. clean the wound with sterile saline. B. pat dry the wound with gauze. C. irrigate the wound with hydrogen peroxide. D. don sterile gloves

Choice A is correct. The nurse should obtain capillary blood glucose as ordered and when the nurse suspects significant alterations in the client's glucose. When obtaining a CBG, the nurse should select a finger that is not edematous or injured. The nurse should ensure the glucometer is calibrated and cleaned for this procedure. The nurse will come into contact with the client's blood, so they must wear gloves. Choice B is correct. The client washing their hands with soap and water is preferred over isopropyl alcohol because this would potentially contaminate the sample. Both methods are acceptable. Choice C is correct. Glucometers can spread blood-borne pathogens and should be disinfected in between use.

The nurse is preparing to obtain capillary blood glucose (CBG) for a client with diabetes mellitus. The nurse should take which action? Select all that apply. - Apply gloves for this procedure - Have the client wash their hands with soap and water prior to blood collection - Collect the second blood drop on the test strip - Prick the central part of the finger for the sample - Clean and disinfect the glucometer in between uses

Choice C is correct. Priming new intravenous (IV) tubing is done to prevent a medical emergency known as an air embolism. Priming involves placing fluid in the IV tubing to remove air before attaching it to the client, preventing air from entering the circulatory system. Air embolism occurs when an air bubble causes an obstruction of blood flow (at the outlet where the right ventricle opens into the pulmonary artery), resulting in breathing problems, chest pain, or cardiac arrest. Obstructive shock can occur in air embolism. Immediate intervention is to place the client in the left lateral Trendelenburg position so that the air floats superiorly and away from the right ventricular outlet, thus relieving the obstruction.

The nurse is preparing to prime a new line of IV tubing. The nurse understands that priming intravenous tubing is crucial because it prevents which treatment complication? A. Medication toxicity B. Infiltration C. Air embolism D. Extravasation

Choice B is correct. PPE necessary to discontinue a peripheral vascular access device includes a pair of clean gloves. Additional PPE may be used if required by the client's clinical condition (if they are in isolation).

The nurse is preparing to remove a peripheral vascular access device. Which personal protective equipment (PPE) is necessary for this procedure? A. Fluid resistant gown B. Clean gloves C. Surgical mask D. Sterile gloves

Choice C is correct. Placing the client in a supine or Trendelenburg position while removing a central venous catheter would be appropriate. One of these two positions is acceptable to decrease the risk of air embolism. The client should not have their head elevated for this procedure because that would increase the risk of air embolism.

The nurse is preparing to remove an intrajugular central venous catheter. It would be appropriate to place the client in which position for this procedure? A. Reverse Trendelenburg B. Left lateral C. Trendelenburg D. High-Fowler's

Choice D is correct. Having the client engage in early ambulation will minimize the risk of atelectasis, venous thromboembolism, and pneumonia. The client will be encouraged to ambulate as early as eight hours following surgery.

The nurse is providing preoperative teaching to a client scheduled for a pneumonectomy. Which of the following statements should the nurse make to the client? A. "You must lay on your nonoperative side immediately following this surgery." B. "You can expect your lung function to return to normal within two to six hours." C. "You will want to avoid coughing after this surgery as you will be suctioned using a catheter." D. "You will be encouraged to get up and ambulate immediately after your surgery."

Choice C is correct. Once the nurse has observed a flashback in the chamber, the nurse needs to advance the catheter ¼ inch (0.6 cm) into the vein and, at the same time, loosen the stylet. This step is important because the nurse needs to ensure that the catheter is in the tunica intima of the vein. Failing to do this could cause the client to experience infiltration or extravasation.

The nurse is starting a peripheral vascular access device for a client. The nurse inserted the device into the client and observed a flashback of blood in the chamber. The nurse should then A. advance the VAD approximately 3 inches (7.62 cm) into the vein and loosen the stylet. B. remove the stylet and secure the catheter using a transparent dressing. C. advance the VAD approximately ¼ inch (0.6 cm) into the vein and loosen the stylet. D. remove the stylet and release the tourniquet.

Choice A is correct. A percutaneous kidney biopsy will be required to lay supine immediately following the procedure to achieve and maintain hemostasis. A back roll may be used to provide additional support.

The nurse is teaching a client who is scheduled for a percutaneous kidney biopsy. Which of the following information should the nurse include? A. "You will need to lay flat immediately after this procedure." B. "A heating pad will be applied to the affected area for pain relief." C. "Before you eat, your gag reflex will need to return." D. "You can resume your regular activities and diet right after the procedure."

Choices C and E are correct. These actions by the student are incorrect and require follow-up by the nurse. Clean gloves are used to clean the perineum, not the labia. When cleaning the labia with the antiseptic solution, the student should wear sterile gloves. The student should first separate the labia with the fingers of the nondominant hand to fully expose the urethral meatus. Once the non-dominant/nonsterile hand touches the patient, it is now considered contaminated (non-sterile). Therefore, the nonsterile nondominant hand is held in this position throughout the procedure until the catheter is inserted. While holding the labia apart with the nondominant non-sterile hand, the student nurse should clean the labia with the antimicrobial solution using their sterile dominant hand. Acting correctly will greatly decrease the risk of contamination. Following this, the student should pick up the lubricated catheter with the sterile dominant hand, place the distal end of the catheter in the receptacle, and steadily insert the catheter into the urethral meatus. The drainage bag of the urinary catheter should not be secured to the bed's side rails because it will move with the side rails and

The nurse observes a student inserting an indwelling urinary catheter into a female client. Which action by the student requires follow-up by the nurse? The student (Select all that apply) - applies clean gloves to clean the perineal area with soap and water. - asks the client to bear down as the catheter is slowly inserted through the urethral meatus. - separates the labia with the fingers of the dominant hand when cleaning with antiseptic solution. - secures the catheter tubing to the inner thigh. - attaches the drainage bag to the side rails of bed.

Foul smelling drainage Oral temperature Purulent wound drainage

The nurse performs a physical assessment for a client three days post-operative following a radical hysterectomy. Select three (3) assessment and vital sign findings that are highly concerning. Incisional pain Approximated wounds Pulse rate Foul smelling drainage Nausea after pain medication Oral temperature Purulent wound drainage

Choice A is correct. Respiratory status should always be given priority in any assessment. Residual sedation from anesthesia may cause an impairment in gas exchange. Thus, respiratory assessment is essential. Assessments are continuous, using preoperative and intraoperative data as bases for comparison. The estimates made in the PACU include respiratory status (airway, pulse oximetry), cardiovascular status (blood pressure), temperature, central nervous system status (level of alertness, movement, shivering), fluid status, wound status, GI status (nausea and vomiting), and general condition. These assessments are initially made every 10 to 15 minutes.

The nurse plans care for a client immediately post-operative. The nurse should initially assess the client's A. respiratory status. B. tolerance to by-mouth (PO) fluids. C. pain level. D. ability to move the extremities.

Choice B is correct. These observations are inappropriate and require follow-up. Inflating the cuff of the tracheostomy is not something that is done before suctioning. The purpose of the cuff is to keep the tracheostomy in place. Overinflation can result in significant damage; thus, monitoring the cuff pressure should be done with a manometer. Normal pressure should range between 14-20 mmHg.

The nurse preceptor is observing a newly hired nurse care for a client with a tracheostomy. Which of the following actions by the newly hired nurse would require follow-up by the observing nurse preceptor? A. Applies suction to the catheter as it is removed in a twirling motion. B. Inflates the tracheostomy's cuff with 5 mL of air prior to suctioning. C. Preoxygenates the client with 100% oxygen prior to suctioning. D. Provides mouth care after suctioning the tracheostomy.

Choice C is correct. A PET scan is primarily indicated to detect cancers and their response to treatment. Before a PET scan, the client is instructed to be nothing by mouth (NPO) four to six hours before the exam and have a glucose level below 150 mg/dL. The reasoning is that this exam primarily looks at cancerous tissue, which uses a substantial amount of glucose. If the radioisotope is metabolized in the body, similar to glucose, it will accumulate in the most active areas. Glucose greater than 150 mg/dL or less than 60 mg/dL will alter the results.

The nurse prepares a client for a positron emission tomography (PET) scan. Which laboratory data is necessary to obtain before this test? A. Urine specific gravity B. Liver function tests C. Blood glucose D. Creatinine kinase

Choice C is correct. The basilic vein is the third site of choice for venipuncture and IV insertion in the arm. The basilic vein (labeled in the image below) is located medial to the other major veins of the arm ( ulnar side of the arm). The basilic vein is a less preferred venipuncture site than the median cubital vein and the cephalic veins because it is not as superficial, typically not well anchored, and tends to roll. This makes it difficult to access with a needle and poses a greater risk of injury to the adjacent median nerve and brachial artery. Therefore, the basilic vein should only be used if the median cubital vein and the cephalic veins are not accessible or usable.

The nurse prepares to insert a peripheral IV into the basilic vein of the right arm. Based on the diagram, indicate where the nurse would attempt this puncture. See the exhibit. View Exhibit A. In the center of the antecubital fossa B. Not shown in the diagram C. Medial aspect of the forearm D. Lateral aspect of the arm

Choice A is correct. When the nurse plans to insert a peripheral vascular access device, the nurse should hold the vascular access device bevel up and align the catheter at a 10-30 degree angle. This is an appropriate angle because if the angle were higher than 30 degrees, the nurse would risk going through the vein and causing the client discomfort and a hematoma. The nurse should then observe for blood return in the catheter or flashback chamber of the catheter, indicating that bevel of needle has entered the vein. Once this blood return is observed, the nurse should then advance VAD approximately ¼ inch (0.6 cm) into vein to ensure it is in the tunica intima of the vein.

The nurse prepares to insert a peripheral vascular access device (PVAD) in the client's cephalic vein. The nurse plans to align the catheter how many degrees above the targeted vein? A. 10-30 degrees B. 30-45 degrees C. 45-90 degrees D. 45-60 degrees

Choice A is correct. Open suction of a tracheostomy tube requires an aseptic technique. After setting up a sterile field and applying sterile gloves, the nurse would designate one hand as contaminated and ensure the other remains sterile. The contaminated hand should be used to connect/disconnect the catheter tubing, use the resuscitation bag, and operate the suction control. If preoxygenation is indicated, the nurse would use the contaminated hand to administer it.

The nurse prepares to suction a tracheostomy tube to help clear a patient's secretions. After opening the package, filling the cup with sterile water, and putting on sterile gloves, the nurse uses one hand to connect the catheter to the suction. What action would be most appropriate for the nurse to take next? A. Use the contaminated hand to preoxygenate the patient prior to suction. B. Use the sterile hand to slowly insert the catheter while applying intermittent suction. C. Restart the procedure due to contamination after applying sterile gloves. D. Assess the patient's baseline oxygenation status.

Choice B is correct. The client's potassium is considerably low and should be reported to the provider. A client scheduled for surgery must have a complete blood count (CBC) and a complete metabolic panel (CMP) to determine if any abnormalities are evident. The potassium being low requires follow-up.

The nurse reviews a client's laboratory data before a scheduled surgery. Which laboratory data requires immediate follow-up? See the image below. A. Sodium level B. Potassium level C. BUN D. Creatinine

Legal The surgeon has not obtained informed consent Discharge planning The client stated he was going to drive himself home after the procedure

The nurse reviews the completed pre-operative assessment Click to highlight the findings on the assessment that require follow-up Demographics ID verified and band applied Legal The surgeon has not obtained informed consent Medications Client took his prescribed phenytoin with a sip of water this morning Diet The client reports his last meal and fluid intake was the previous day at 2200 Discharge planning The client stated he was going to drive himself home after the procedure

Choice C is correct. This statement requires follow-up because it is incorrect. Thick, tenacious secretions that clear with coughing cause rhonchi.

The nurse supervises a student nurse auscultating lung sounds on a group of clients. Which statement by the student nurse would require follow-up? A. "Wheezes arise from the small airways and usually do not clear with coughing." B. "A pleural friction rub causes loud, rough, scratching sounds usually during inspiration." C. "Thick, tenacious secretions that clear with coughing cause crackles." D. "Fluid or secretions in large airways typically cause coarse crackles."

Choice C is correct. Nitroglycerin transdermal patches should be temporarily removed during the procedure because they may burn the client. The transdermal patch may contain aluminum which is contraindicated for an MRI. Moving the patch would not be helpful as it should be totally removed during the procedure.

The nurse supervises a student nurse prepare a client for a magnetic resonance imaging (MRI) test. Which of the following actions by the student nurse would require follow-up by the nurse? The student A. asks the client if they have claustrophobia. B. instructs the client to apply earplugs before the exam. C. moves the nitroglycerin patch from the torso to the back. D. tells the client that they will not have any exposure to radiation.

Choice D is correct. After the surgery, the client will be prescribed VTE prevention (sequential compression devices, subcutaneous enoxaparin). The client should not take an anticoagulant or antiplatelet for 5-7 days or as directed by the surgeon before the surgery. This would raise the risk for intra- and postoperative hemorrhage. Other medications such as vitamin E, garlic, and aspirin should be avoided because these will increase the risk of bleeding.

The nurse teaches a client scheduled for an upcoming total hip arthroplasty. Which of the following statements by the client would require follow-up? A. "I will need to bathe with chlorhexidine gluconate solution (CHG) the night before surgery to prevent an infection." B. "I will need to deep breathe and cough every 2 hours." C. "I will have to attend physical therapy sessions following my surgery." D. "I will be prescribed an anticoagulant and need to take it with a sip of water on the day of surgery."

Choices B, C, and D are correct. There is no contraindication for oral temperature measurement in any of these clients. The oral temperature is measured with the probe placed under the tongue and the lips closed around the instrument. Oxygen delivered by nasal cannula does not affect the accuracy of the measurement. An adult client with chest pain (Choice B), diarrhea (Choice C), or an earache (Choice D) can receive oral temperatures.

The nurse works on a medical-surgical unit and is responsible for assessing the client's vital signs. Which of the following clients should have their temperature measured orally? Select all that apply. - A 61-year-old woman who had oral surgery - A 44-year old man with chest pain on oxygen via nasal canula - An 83-year-old woman with diarrhea - A 29-year-old client with an earache - A 6-year-old client with a sore throat and difficulty swallowing

Choice B is correct. A 24-hour urine collection may be ordered to evaluate the type and severity of certain renal disorders. The nurse is responsible for providing the collection container and educating the patient on the correct process of collecting the specimen. At the beginning of the 24-hour urine procedure, the patient should not collect or save the first urine specimen. This first void is considered "old urine" or urine in the bladder before the test began. This specimen should be flushed and the time at which its discarded is noted. After the first discarded specimen, urine is collected for the next 24 hours.

The physician has ordered a 24-hour urine specimen. After explaining the procedure to the client, the nurse collects the first specimen. What is the next step to do with the urine specimen? A. Place it in a separate container and later add to the collection. B. Discard it, then the collection process begins C. Test it, then discard D. Save as part of the 24-hour collection

Choice C is correct. When administering an enema for fecal impaction, the nurse should place the patient in the left Sims' position. This allows the medicine to move naturally throughout the colon.

The primary care physician has ordered an enema for a patient with fecal impaction. The nurse would be correct in placing the client in which position before administration? A. Trendelenburg's position B. Semi-Fowler's position C. Left Sims' position D. Right-side with the head of the bed lowered

Choice B is correct. Paralytic ileus is characterized by an interruption of peristalsis, which causes a client to have abdominal distention, persistent nausea and vomiting, hiccups, and decreased bowel sounds. An NGT is placed to decompress the stomach and relieve the pressure from the ileus.

The primary healthcare provider (PHCP) prescribes the insertion of a nasogastric tube for a client with paralytic ileus. The nurse understands that the primary purpose of placing this tube is to A. feed the client. B. decompress the stomach. C. irrigate the stomach. D. administer medications.

Choice D is correct. Making assumptions or generalizations about a patient's spiritual needs based on ethnic or religious affiliation is almost sure to be an oversimplification. The nurse should be able to identify similarities and differences among the cultural beliefs of the patients. Just because a patient belongs to a certain culture or ethnicity, it is incorrect to generalize their spiritual needs.

The primary objective in identifying similarities and differences among cultural beliefs of a patient is to: A. Communicate with the family B. Make sure the proper diet is ordered C. Perform a spiritual consult D. Avoid making assumptions

Choice D is correct. A devout Muslim patient may request to turn their bed to face Mecca, change their hospital gown, and place a basin of water near their bed for ritualistic handwashing before praying.

What is the most appropriate nursing response when a Muslim patient requests that a basin of water on her bedside table not be emptied? A. Tell her that the water is a health hazard B. Talk with her about why she should not have it there C. Empty it because it could spill and wet the bed D. Support and accommodate her preference

Choice C is correct. When caring for a patient who is in spiritual distress; the nurse should listen to the patient first. Goals and expected outcomes for patients in spiritual distress need to be individualized and may include a patient achieving some of the following: Exploring the origin of spiritual beliefs and practices Identifying factors in life that challenge spiritual beliefs Exploring alternatives given these challenges: denying, modifying, or reaffirming beliefs, developing new beliefs Identifying spiritual supports Reporting or demonstrating a decrease in spiritual distress after successful intervention

When a hospice patient tells the nurse, "I feel no real connection with God," what is the nurse's most appropriate response? A. Give the patient a hug and tell her that her life still has meaning B. Arrange for a spiritual adviser to visit the patient C. Ask the patient if she would like to talk about her feelings D. Call in a close friend or relative to talk with the patient

Choices A, B, D, and E are correct. Amish live a life that is generally strictly separate from society. While women are highly respected and valued, men hold the authority in the home. Traditional and alternative health care is appreciated, although many live without insurance. Health is believed to be a gift from God.

When caring for an Amish patient, what does the nurse know to be true? Select all that apply. - They use traditional and alternative health care. - Funerals are conducted in the home. - The authority of women and men are equal. - Many choose to live without health insurance. - Health is believed to be a gift from God.

Choice C is correct. A nurse should arrange for a trained healthcare interpreter during each encounter with a client who speaks a different language. Additionally, the use of the interpreter should be documented within the subsequent documentation of the encounter.

When communicating with a client who speaks a different language, the nurse should do which of the following? A. Speak loudly and slowly B. Stand close to the client and speak in an exaggerated volume C. Arrange for a trained health care interpreter when communicating with the client D. Speak to the client and family together to promote comprehension

Choice A is correct. Since the list of suggested transcultural assessment questions is extensive, nurses can usually not conduct a complete assessment for each patient on admission to inpatient or outpatient care. Therefore, the nurse must determine which questions to ask based on the patient's symptoms, learning needs, and potential health effects of culture-based practices. A patient's behavior is influenced in part by his cultural background. Although certain attributes and attitudes are associated with particular cultural groups, not all people from the same cultural background share the same behaviors and views. When caring for a patient from a different culture, nurses need to be aware of and respect the patient's cultural preferences and beliefs. Failure to do so may cause the patient to feel that the nurse is insensitive and indifferent, possibly even incompetent. When performing a transcultural assessment, it is essential not to stereotype a patient based on what you believe their cultural beliefs/practices are. The best way to avoid stereotyping is to view each patient individually and find out their cultural preferences. Using a culture assessment tool or questionnaire can hel

When performing a transcultural assessment, the nurse must: A. Determine which questions to ask the client based on the potential health effects of culture-based practices. B. Wait until the nurse-patient relationship is established before asking questions. C. Ask all questions for completeness of the assessment. D. Include all questions as part of an admitting assessment.

Choices A, C, D, and E are correct. Silence, eye contact, touch, and bodily posture are all forms of nonverbal communication that can be viewed and perceived differently among members of different and diverse cultures. Some cultures can see silence to be a lack of attention, while others can perceive silence as a compassionate way that understanding is conveyed. Some view eye contact as aggressive and hostile while other cultures see eye contact as connectedness with others. Some cultures perceive touch as inappropriate and invasive while others recognize touch as a sign of caring and compassion. Lastly, many bodily postures and gestures differ significantly among various cultures. A smile is a relatively universal sign of joy and happiness.

Which forms of nonverbal communication can be viewed differently among members of different and diverse cultures? Select all that apply. Silence A smile Eye contact Touch Bodily posture

Choices A and C are correct. St. John's Wort, an herbal remedy for depression that may interfere with specific medical treatments and should not be taken without medical supervision. Acupuncture, while generally safe, is not always well-tolerated and should also be approved and supervised by a health care provider.

Which of the following alternative therapies are not considered a low-risk treatment? Select all that apply. St. John's Wort Meditation Acupuncture Relaxation techniques Guided imagery

Choice D is correct. Spiritual distress, as defined by the North American Nursing Diagnosis Association, is the lack of ability by the client to integrate the purpose and meaning of life into connectedness as well as interrelationships with the higher power, self, and others.

Which of the following terms, according to the North American Nursing Diagnosis Association, is defined as the lack of ability by the client to integrate the purpose and meaning of life into connectedness as well as interrelationships with the higher power, self, and others at the end of life? A. Guilt B. Isolation C. Religious distress D. Spiritual distress

Choice A is correct. The patient should be sitting up, leaning over a bedside table with arms rested, feet supported on the ground, or stool so the needle can be inserted appropriately. Usually, only sufficient fluid to lubricate the pleura is present in the pleural cavity. However, excessive fluid can accumulate due to injury, infection, or other pathology. In such a pleural effusion or pneumothorax, the physician may perform a thoracentesis to remove the excess fluid or air to ease breathing. Thoracentesis is also used to introduce chemotherapeutic drugs intrapleurally. The nurse assists the client in assuming a position that allows easy access to the intercostal spaces. Two different client-positioning options are used for the thoracentesis procedure. An upright position is the most preferred approach, allowing access to the posterior approach to thoracentesis. In patients unable to sit up, the supine position is preferred. The preferred upright position is usually a sitting position with the arms above the head, which spreads the ribs and enlarges the intercostal space. The client leans slightly forward, resting the head over the pillow. To ensure that the needle is inserted below th

While scheduling a client for thoracentesis, the nurse understands which of the following is the most preferred position for the procedure? A. Sitting up, leaning over a bedside table, and feet supported on the ground or stool. B. The head of the bed flat with the patient lying on the unaffected side. C. Prone position with both arms extended above the head. D. The head of the bed ele