Learning System 2.0 Fundamentals
A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take?
- Hold the irrigator 1 inch above the eye to prevent the solution from damaging the eye tissue. - Direct the irrigation solution onto the lower conjunctiva sac to prevent injuring the cornea and having contaminated fluid flow down the nasolacrimal duct. - Hold the upper lid against the eyebrow and the lower lid against the cheekbone when irrigating. - Direct the solution from the inner canthus to the outer canthus of the eye to prevent injuring the cornea and having contaminated fluid flow down the nasolacrimal duct.
A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which action should the nurse take?
- Lubricate 5-8 cm (2-3 inches) of the tip of the rectal tube before inserting to decrease risk of irritation or injury to mucosa. - Position client on left side in the Sims' position to allow the solution to flow downward into the sigmoid colon and rectum and promote retention of the enema. - Insert tip of tubing 7-10 cm (3-4 inches) along the rectal wall to prevent dislodging of the tube during the procedure and injury to the rectal mucosa. - Hold the enema container a maximum of 45 cm (18 in) above the rectum to prevent painful distention of the colon.
A nurse is obtaining the blood pressure in a client's lower extremity. Which action should the nurse take?
1. Auscultate for the BP at the popliteal artery 2. Measure while the client is prone if possible. Otherwise, the client should lie supine with the knee flexed. 3. Position the cuff 1 inch above the popliteal artery. 4. Place the bladder of the cuff over the posterior aspect of the thigh.
Correct sequence of steps for an abdominal assessment:
1. Inspect 2. Auscultate 3. Percuss 4. Palpate
A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which action should the nurse take?
Auscultate the apical pulse for 60 seconds to obtain an accurate rate. Document the irregularity in the client's medical record.
A nurse is collecting a urine specimen for culture and sensitivity for a client who has a UTI. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take?
Clamp the tubing below the collection port to allow fresh uncontaminated urine to collect before withdrawing the specimen through the port and placing it in the sterile specimen cup.
A nurse is providing teaching to an older adult client who has constipation. Which statement should the nurse include in the teaching?
Increased peristalsis occurs after food enters the stomach. Sitting on the toilet 30 minutes after eating a meal, regardless of feeling the urge to defecate, is a recommended method of bowel retraining to treat constipation.
A nurse is changing the dressings for a client who is 3 days postoperative following a cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as which of the following types of drainage?
Purulent exudate. - Sanguineous: bright red - Serous: clear to light yellow, watery - Serosanguineous: pale yellow to blood tinged, watery
A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who will have emergency surgery for appendicitis. Which statement indicates a lack of readiness to learn by the client?
The client reports severe pain. They are not able to concentrate and therefor, is not ready to learn a new activity.
A nurse is preparing to anchor with tape the catheter tube for a male client who has a newly inserted indwelling urinary catheter. At which of the following locations should the nurse tape the catheter?
The nurse should secure with tape the client's indwelling urinary catheter to the lower abdomen or the upper aspect of the thigh to eliminate the penoscrotal angle and prevent tissue injury.