Nursing Midterm Prep
Which findings are significant to the initiation of intravenous fluids? (select all that apply). a. the patient's age b. absence of tonsils c. previous experience with IV therapy d. allergy to amoxicillin (Moxatag)
A, C
Giddens (2017) identifies several different exemplars for Clinical Informatics. (select all that apply) a. telehealth b. computerized provider order entry (CPOE) c. pulse oximetry d. barcode medication administration
A. telehealth B. computerized provider order entry (CPOE) d. barcode medication administration
Removal of at least half of the fluid in the catheter balloon will ensure easy removal of the Foley urinary catheter. a. True b. False
B.
The NAP documents "Peri-care given" next to "Urinary Catheter" on a patient with an indwelling urinary catheter. What is the best explanation of what the NAP did after application of clean gloves? The NAP: a. washed the perineal area with soap and water and applied a topical antimicrobial ointment at the urethral meatus around the catheter. b. stabilized the catheter and washed the catheter with soap and water from where the catheter enters the meatus down 4 inches toward the drainage tubing. c. inserted the hub of syringe into balloon port allowing the sterile water to return passively into the syringe and slid the catheter out into a waterproof pad. d. obtained a squirt bottle of warm water and had the patient squirt it over their perineum while sitting on the toilet.
B.
The purpose of allowing the chlorhexidine to dry completely is to promote maximum adherence of the transparent dressing or tape. a. True b. False
B.
If a patient's indwelling catheter is removed at 0900, the patient should be due to void by: a. 1900 - 2100 (7:00 PM to 9:00 PM) b. 1100 - 1200 (11:00 AM to 12:00 PM) c. 1500 - 1700 (3:00 PM to 5:00 PM) d. 0930 (9:30 AM)
C.
Mentoring as a practice in nursing, is a type of: a. communication b. clinical judgement c. collaboration d. safety
C. collaboration
How frequently should a transparent occlusive dressing be changed? a. Every 24 hours and as needed b. Every 48 hours and as needed c. Every 3 days and as needed d. Every 5-7 days and as needed
D.
An empty bladder is easily palpated. True or False
False
The dressing change of an established vascular access device may be delegated to assistive personnel. True or False
False
The fenestrated drape is placed under the patient's buttocks before the procedure. a. True b. False
False
The foreskin must remain retracted following catheterization. a. True b. False
False
The tourniquet should be applied 10 to 12 inches (25 to 30 cm) above the proposed insertion site. True or False
False
0.45% Sodium Chloride is considered a hypotonic solution True or False
True
A nurse is working on a postpartum unit needs to be educated and skilled in caring for both the maternal patient and the infant. True or False
True
Having the patient bear down as if voiding will allow for easier passage of the catheter through the urethral meatus. a. True b. False
True
If uncircumcised, the foreskin of the penis must be retracted before beginning urethral catheterization preparation. a. True b. False
True
Once the catheter is inserted, you should release labial retraction and hold the catheter close to the urethra. a. True b. False
True
Telehealth may provide opportunities to make health care more efficient better coordinated and closer to home. True or False
True
The catheter should be inserted to the bifurcation of the drainage and balloon inflation port in the male patient. a. True b. False
True
The concept of clinical judgement has several different interrelated concepts, as almost all patient care activities involve clinical judgement. True or False
True
The correct position for catheterizing a male patient is supine with legs slightly abducted. a. True b. False
True
The ideal time to initiate breastfeeding is within the first 1 to 2 hours after childbirth. True or False
True
The intravenous catheter should be inserted with bevel up at a 10- to 30- degree angle slightly distal to the actual site of venipuncture. True or False
True
The patient should receive an explanation of the procedure regardless of their consciousness status. a. True b. False
True
The tourniquet should be tight enough to impede venous return but fail to occlude arterial flow. True or False
True
This patient states that she is allergic to materials made from rubber. You select a silicone catheter for her. a. True b. False
True
Using the standardized report sheet (with room to write about systems, IV lines, tasks, etc) helps a nurse organize and prioritize care appropriately. True or False
True
When cleansing the perineum, allow for only one pass with each cotton ball during preparation. a. True b. False
True
When preparing for catheter insertion in a male, cleanse from the urethral meatus to base of glans three times, using a new cotton ball with each cleansing. a. True b. False
True
Your assessment of the patient should include exploring any history of previous catheterizations. a. True b. False
True
Choose the size catheters that would be appropriate for Ms. Roberts: (select all that apply). a. 14 french b. 16 french c. 18 french d. 10 french e. 12 french
A, B
Reasons for lack of urine after inserting a straight catheter include: (Select all that apply.) a. The catheter is outside of the bladder. b. The catheter is inserted in the vagina rather than in the urethra of a female patient. c. The male patient's prostate is preventing urine from exiting the bladder. d. Urethral spasms are preventing urine from exiting the body.
A, B
What assessment skills would you use to determine if local infection is present at the PICC site? (select all that apply). a. inspection b. palpation c. percussion d. auscultation
A, B
A nursing student is watching a nurse catheterize a female patient with an indwelling catheter. Which of the following, if it occurs, indicates a break in sterile technique? (Select all that apply.) a. The nurse inserts the urinary catheter, and when urine does not return, removes the catheter and makes a second attempt to locate the urethra with the same catheter. b. The nurse lubricates the catheter and places it back into the sterile tray when it uncoils and touches the bed. c. After the nurse cleans the labia, the labia become slippery and close as the nurse attempts to obtain a clear view of the urethra. d. The nurse advances the catheter another 2.5 to 5 cm (1 to 2 inches) after urine appears, releases the labia, and holds onto the catheter with the nondominant hand. e. The nurse uses forceps and a new cotton ball when cleansing the area, wiping along the far labial fold, the near labial fold, and directly over the center of the urethral meatus.
A, B, C
A patient appears very anxious as you prepare to insert an IV catheter. What suggestion(s) are most appropriate for you to give the patient? (select all that apply). a. visual imagery b. deep breathing c. avoiding looking at the site d. tell the patient you will return in 15 minutes e. have the patient squeeze the assistive personnel's hand with the unaffected extremity
A, B, C
Identify the reasons why a patient with an indwelling catheter may have less than 30 mL per hour of urine in the collection bag: (Select all that apply.) a. The catheter has slipped out of the bladder. b. The patient is severely dehydrated. c. The patient's kidneys are damaged or injured. d. The patient has a UTI.
A, B, C
You have finished providing instructions to the NAP on catheter care and removal of an indwelling catheter. Which of the following situations should the NAP report to you? (select all that apply.) a. a patient has 800 mL of clear amber urine in her drainage bag b. a patient has been incontinent of stool and his scrotum appears red c. a patient's drainage bag is below the level of the bladder d. a patient's catheter was removed at 1500
A, B, D
You return to the patient's room one hour after inserting an indwelling urinary catheter to evaluate the outcome of the procedure. What actions would you take? (select all that apply). a. observe that the patient has approximately 100 mL of clear, straw-colored urine in the drainage bag b. palpate above the patient's symphysis pubis c. offer the patient a glass of orange juice d. determine that the drainage system is intact without urine leaking around the catheter e. ask the patient whether he is having any discomfort
A, B, D, E
Which of the following unexpected outcomes, if experienced by Ms. Roberts, should be reported to her health care provider? (select all that apply). a. lack of urine after one hour b. more than 2500 mL of urine produced consistently every 24 hours (polyuria) c. urine leakage around the catheter d. inability to advance the catheter into the bladder e. the patient consistently produces less than 30 mL of urine per hour f. patient continues to complain of discomfort after insertion
A, B, D, E, F
The nurse has a sterile urinary catheter and sterile gloves. Choose the remaining equipment the nurse will need to insert a straight urethral catheter: (Select all that apply.) a. Sterile cotton balls b. Antiseptic solution c. Sterile urinary collection bag d. Water-soluble lubricant e. Clean cotton balls f. Sterile forceps g. Sterile water in a syringe (without needle)
A, B, D, F
A nurse is evaluating a patient's IV infusion. What should the nurse be checking? (select all that apply). a. observing the patient for signs of discomfort at the IV insertion site, and observing the IV site for signs and symptoms of complications b. counting flow rate or checking rate on infusion pump c. determining if the patient has a history of allergy to latex or iodine d. noticing how many times the alarm on the electronic infusion pump has sounded for documentation purposes e. determining the patient's response to therapy
A, B, E
Which of the following require the use of an indwelling catheter? (select all that apply). a. a patient scheduled for surgical repair of bladder b. to determine whether there is any residual urine in patient's bladder c. an incontinent patient with significant impaired skin integrity d. to obtain a sterile sample from a patient who is unable to adequately cleanse his perineal area e. an incontinent male who is able to completely empty his bladder
A, C
A busy medical-surgical unit is short staffed. It is time for routine vital signs. The alarm in one patient's electronic infusion device is sounding because the IV bag is empty, and another patient has new orders for initiating an IV infusion. Which task(s) may be delegated to the NAP? (select all that apply). a. getting the IV tray of IV supplies b. initiating the IV infusion according to health care provider's orders c. having the assistive personnel inform the nurse when IV fluids are low in volume d. taking routine vital signs e. hanging a new bag of IV fluids to replace the empty one
A, C, D
A 90 year old terminally ill patient who requires Foley catheterization due to skin breakdown from urinary incontinence. She is weak and unable to maintain a position in bed without the aid of pillows. You and the NAP are in the room to perform the procedure. What tasks can you delegate to the NAP? (select all that apply.) a. assisting the patient into position for catheterization b. preparing the sterile field c. inserting the foley catheter d. holding the flashlight for catheter insertion e. holding the patient's hand
A, D, E
What are the advantages of a transparent dressing over a gauze dressing? (select all that apply). a. it remains intact longer without development of infection at site b. a transparent dressing is more effective than a traditional gauze dressing in reducing entrance of microorganisms c. sterile technique is unnecessary in the hospital setting d. it is more effective if the patient is diaphoretic e. it allows visualization of the exit site
A, E
A patient has been receiving IV antibiotics and as a result has had several IV site locations. What action can the nurse take to promote venous distention in the patient? (select all that apply). a. apply a warm pack to the arm for several minutes b. elevate the arm 10 to 30 degrees c. teach the patient relaxation techniques d. use the side of paralysis to avoid a vasoconstriction response to catheter insertion e. choose a site distal to the previous IV site f. rub or stroke the patient's arm g. tap the patient's veins multiple times
A, F
A patient had an indwelling catheter for 3 weeks. The patient had the catheter removed 3 hours ago and now complains of having to go to the bathroom frequently and that it is painful to void. Which instruction is appropriate for the nurse to give the patient? a. "This is a normal occurrence after having a catheter in place for more than several days." b. "It sounds like you have a UTI. I will notify your health care provider." c. "I will need to inspect your perineal area and wash and dry the area." d. "If these symptoms continue, I will notify your health care provider to see if we can reinsert the catheter."
A.
Any sign of infection should be reported to the health care provider before removing a Foley catheter. a. True b. False
A.
At least 10 cm (4 inches) of an indwelling urinary catheter that exits the meatus should be wiped with a clean wash cloth during routine care. a. True b. False
A.
At what angle should an IV catheter puncture the skin and vein during insertion in a middle-aged adult? a. 10 to 30 degree angle b. 45 degree angle c. 90 degree angle d. 5 to 10 degree angle
A.
Catheter care is performed to remove bacteria that could ascend through the urethral canal and lead to an infection. a. True b. False
A.
Ensuring that the patient receives adequate fluids will improve the probability that the patient will void within 6 to 8 hours after catheter removal. a. True b. False
A.
NAP can perform catheter care. a. True b. False
A.
NAP can remove indwelling urinary catheters. a. True b. False
A.
Sterile technique is required to apply a new dressing of a vascular access device. a. True b. False
A.
Swelling, drainage, and irritation of the urethral meatus may indicate localized infection. a. True b. False
A.
The nurse is catheterizing a male patient and obtains a clear amber urine return. As the nurse begins to inflate the balloon the patient complains of pain and resistance is felt. What is the nurse's best action? a. Allow fluid to flow back into syringe, and advance the catheter a little more before attempting to reinflate. b. Have the patient take slow deep breaths inhaling through the nose and exhaling through the mouth. c. Lift penis to position perpendicular to patient's body, and apply light traction. d. Advance catheter to bifurcation of the drainage and balloon inflation port.
A.
The nurse is changing the dressing over a triple-lumen CVAD and assesses the exit site. Which observation would be cause for concern and should be reported to the health care provider? a. Patient afebrile; redness and tenderness at exit site b. Dried dark red blood noted on previous dressing c. Clamps are closed on each of the triple lumens d. Absence of exudate and swelling at insertion site
A.
The nurse is inserting an indwelling Foley catheter in a male patient. The nurse asks the patient to bear down as if to void, and slowly inserts the catheter through the urethral meatus. The nurse advances the catheter and meets resistance. What is the nurse's best initial action at this time? a. Ask the patient to take slow deep breaths while inserting the catheter slowly. b. Withdraw the catheter and notify the health care provider. c. Apply more force to insert the catheter inward. d. Remove the catheter, apply more lubricant, and reinsert.
A.
The nurse is preparing an IV infusion prior to initiating an IV. The nurse has already verified the IV solution using the six rights of medication administration. The nurse has checked the solution for clarity, color, and expiration date. Which of the following describes the procedure correctly? a. The nurse opens the infusion set and places the roller clamp approx. 2 to 5 cm (3/4 to 2 inches) below the drip chamber and moves the roller clamp to the "off" position. The nurse removes the protective sheath over the IV tubing port on plastic IV solution bag. The nurse removes the sheath from the insertion spike and inserts the spike into the IV bag, fills the drip chamber 1/3 to 1/2 full and primes the infusion tubing with IV solution, making sure there are no air bubbles. b. The nurse removes the protective sheath over the IV tubing port on plastic IV solution bag. The nurse opens the infusion set and places the roller clamp 1 to 2 cm (1/2 to 3/4 inch) above the Y-site and removes the sheath covering the insertion spike. The nurse inserts the spike into the medication port of the plastic IV solution bag and fills the drip chamber 1/2 full. The nurse primes the infusion tubing with IV solution, making sure there are no air bubbles. c. The nurse opens the infusion set and places the roller clamp 2.5 to 5 cm (1 to 2 inches) below the drip chamber and moves the roller clamp to the "on" position. The nurse removes the protective sheath over the air port of the IV bag and spikes the tubing into the air port. The nurse allows the drip chamber to fill completely by gravity and turns the roller clamp to the "off" position. d. The nurse opens the infusion set, removes the protective sheath of the insertion spike and spikes the IV bag in any available port.
A.
The nursing assistive personnel (NAP) reports leakage around a patient's urinary catheter. What action should the nurse take first? a. Attempt to reinflate the balloon. b. Increase the patient's fluid intake and reassess in 1 hour. c. Remove the catheter and replace with a smaller size. d. Obtain a urine specimen.
A.
Which of the following is the best example of documentation on a patient with a urinary catheter? a. Catheter care provided; no encrustation noted. Foley catheter patent and draining clear yellow urine to bedside drainage bag. b. Catheter care provided. 14 French catheter intact with approximately 30 mL urine in bedside drainage bag. c. Unable to palpate urinary bladder. Patent denies discomfort; indwelling catheter draining well. d. Patient instructed on signs and symptoms of UTI and how to prevent while catheterized.
A.
Why is regular assessment of the vascular access device placement site important? a. Long-term IV therapy increases risks for impaired skin integrity and infection. b. There is a need for frequent dressing changes. c. The nurse must notify the health care provider of the patient's condition. d. Catheter lumens become easily occluded.
A.
You are going to remove an indwelling catheter. How can you determine what size syringe to obtain to deflate the balloon of the catheter? a. By looking at the size printed on the balloon inflation valve of the catheter b. By looking at another catheter on the supply shelf and reading the label c. By using a standard 10-mL syringe, as most catheters have a 5-mL balloon d. By looking at the size printed on the catheter where it connects to the drainage tubing
A.
You receive an order to obtain a urine specimen for culture and then discontinue the indwelling catheter. Which of the following is correct regarding delegation? a. The NAP can obtain the urine specimen and remove the catheter. b. You should obtain the urine specimen and the NAP can remove the catheter. c. The NAP can obtain the urine specimen and you should remove the catheter. d. You should never delegate either task.
A.
You should remove the old dressing in the direction the catheter was inserted. a. True b. False
A.
Your assessment of a patient following removal of an indwelling urinary catheter should include urinary frequency. a. True b. False
A.
Which of the following lab results for Chris Frasier are indicative of his diagnosis of Heart Failure? a. b-type natruiretic peptide (BNP) = 540 pg/mL b. blood urea nitrogen (BUN) = 25 mg/dL c. sodium (Na) = 138 mEq/L d. hematocrit 40.2%
A. b-type natruiretic peptide (BNP) = 540 pg/mL
All of the following are abnormal assessment findings for a woman who is 3 days postpartum, except: a. breasts that are starting to become fuller b. red and cracked nipples c. large amount of lochia with multiple golf ball size clots d. soft, boggy uterus
A. breasts that are starting to become fuller
What is it called when a person says one things verbally, but conveys the opposite in nonverbal behavior? a. double message b. cynicism c. degree of openness d. paraphrasing
A. double message
Regina Fields has the medication buprenorphine ordered. This medication has which of the following FDA labeled use? a. opioid dependence b. nerve pain c. hypertension d. thrombosis prevention
A. opioid dependence
Therapeutic communication skills can be applied to the nurse-patient relationship as well as nurse-nurse relationships. When communication with a preceptor in a feedback situation, which of the following communication responses would be appropriate: a. reflection b. probing c. anxious silence d. asking multiple questions
A. reflection
A patient had an indwelling catheter for 3 weeks. The patient had the catheter removed 3 hours ago and now complains of having to go to the bathroom frequently and that it is painful to void. Which instruction is appropriate for the nurse to give the patient? a. this is a normal occurrence after having a catheter in place for more than several days b. it sounds like you have a UTI. I will notify our health care provider c. I will need to inspect your perineal area and wash and dry the area d. if these symptoms continue, I will notify your health care provider to see if we can reinsert the catheter
A. this is a normal occurrence after having a catheter in place for more than several days
You have a basin with warm water, soap, washcloth, towel, and bath blanket. Choose the remaining items you will need to perform catheter care: (select all that apply). a. a urine collection bag b. an absorbent bed pan c. clean gloves d. scissors and/or a safety razor e. urinary catheter kit
B, C
Which of the following sites should be avoided when initiating an intravenous infusion? (select all that apply). a. the foot of a child b. the left arm of a patient who has a history of a left masterctomy c. an area of venous bifurcation or palpation of valves d. site proximal to a previous venipuncture e. the antecubital fossa f. sclerosed or hardened cordlike veins g. inner wrist h. inner arm i. dorsal surface of the hand in an adult j. side of paralysis k. extremity with dialysis shunt
B, C, E, F, G, J, K
The nurse is performing a dressing change for a central vascular access device. The nurse performs hand hygiene, applies clean gloves and a mask. The nurse removes the old dressing in the direction opposite of how the catheter was inserted, noting drainage and appearance of insertion site. The nurse inspects the catheter and hub for intactness, removes clean gloves, and performs hand hygiene. The nurse opens the dressing kit and applies clean gloves. The nurse cleans the exit site with alcohol swabs by swabbing the exit site in a horizontal plane, then a vertical plane, followed by a circular motion (from the middle outward). The nurse repeats with chlorhexidine swabs and applies a transparent dressing. The nurse labels the dressing with date, time of dressing change, and initials. The nurse disposes of soiled supplies, removes gloves, performs hand hygiene, and documents the procedure. Which of the following actions made by the nurse require correction? (Select all that apply.) a. The type of gloves worn to remove the old dressing b. The type of gloves worn to apply the new dressing c. The direction the nurse removed the old dressing d. The direction the nurse used to clean the exit site e. The information the nurse put on the label of the new dressing f. The time between swabbing the site and application of dressing
B, C, F
You are reviewing the signs of a UTI with NAP/family members. Which of the following urine characteristics require subsequent notification of the health care provider? (select all that apply). a. amber b. red c. ammonia smell d. less than 30 mL per hour of urine output e. cloudy f. dark amber
B, D, E, F
Which of the following are evaluation measures used to determine if the patient is experiencing either fluid volume deficit or fluid volume overload? (select all that apply). a. checking IV site for swelling b. measuring daily weight c. observing patient's ability to ambulate 25 feet three times a day d. monitoring intake and output e. administer diuretic as ordered f. auscultating lung sounds
B, D, F
Identify the indicators of a UTI: (Select all that apply.) a. Cool and clammy skin b. Fever c. Urinary drainage d. Complaints of pain e. Hypothermia f. A feeling of bladder fullness g. Abdominal pressure and discomfort h. Cloudiness of the urine
B, D, G, H
Which of the following steps should you take before removing fluid from the balloon in a Foley catheter? (Select all that apply.) a. Attach a 2-mL syringe to the balloon port and aspirate the fluid. b. Attach a 10 mL or larger syringe to the balloon port and allow the water to passively fill the syringe. c. Attach a 10- or 20-mL syringe to the balloon port and forcibly aspirate the water. d. Cut the balloon port and allow the water to slowly drain into a sterile basin. e. Gently aspirate the syringe plunger if water remains in the balloon.
B, E
As part of catheter insertion assessment, where should the nurse palpate? a. At the costovertebral angle b. Above the symphysis pubis c. Starting at the right iliac crest and moving upward along the midclavicular line d. Midway between the xyphoid process and symphysis pubis
B.
Before inserting a straight catheter, you review with the patient why you are doing so. Which of the following explanations from the patient would indicate that he understood why a straight catheter insertion was necessary? (select all that apply.) a. "I a going to have surgery and a catheter will prevent me from having trouble passing urine after surgery." b. I am uncomfortable because I am unable to empty my full bladder. Insertion of a catheter will relieve my discomfort and empty my bladder." c. "During the day when I am awake, I completely empty my bladder. When I am asleep at night, I lose bladder control."
B.
Reduced fluid intake decreases bacterial growth in the urinary system. a. True b. False
B.
The nurse has been called to make a home visit to a patient with a history of a spinal cord injury and an indwelling Foley catheter. The patient appears diaphoretic and his face is flushed. The nurse takes the patient's vital signs with the following results: Temperature 98.4°F, pulse 54, respirations 20 and blood pressure 160/100. The patient's head of the bed is elevated. What action should the nurse take next? a. Notify the health care provider. b. Check for any kinks in catheter tubing. c. Have the patient take slow deep breaths. d. Lower the head of the bed.
B.
The nurse has inserted a catheter 7.5 cm (3 inches) in a female patient and obtains no urine return even though her bladder is distended. What action should the nurse take at this time? a. Remove the catheter and have another nurse attempt to catheterize the patient. b. Leave the catheter in vagina as a landmark and insert another sterile catheter. c. Remove the catheter and reinsert into the urethra. The nurse may straighten the urethra by inserting one finger of sterile gloved hand inside the vagina and applying gentle pressure upward. d. Inflate the balloon and reassess in 1 hour for urine return in the bedside drainage bag.
B.
The nurse is reviewing urinary catheter care with a newly hired nursing assistive personnel (NAP). Which statement made by the NAP indicates further instruction is needed? a. "Urinary catheter care is a clean procedure; sterile gloves are an unnecessary expense." b. "The bedside drainage bag should only be emptied when it is full." c. "During catheter care, you should relocate the tape that anchors the catheter and replace it as necessary." d. "Condom catheter care can be delegated to NAP and family members."
B.
The primary purpose for writing the date, time, and initials on the dressing is accountability. If the dressing should come off, the nurse who performed the dressing change can be identified and given further instruction. a. True b. False
B.
When providing indwelling catheter care, you should clean around the anchor tapes to prevent the catheter from slipping out of the urethra. a. True b. False
B.
Which of the following actions associated with Foley catheterization could cause a potential problem? a. The bedside drainage bag is attached to the bed frame. b. Keeping the foreskin retracted after catheterization. c. Failing to test the balloon by injecting fluid from prefilled sterile water syringe into the balloon port prior to insertion. d. Cleansing the far labial fold, the near labial fold, and directly over the center of urethral meatus using a new swab with each area.
B.
Within 6 to 8 hours of urinary catheter removal, patients should be able to void, without difficulty, at least 75 to 100 mL of urine. a. True b. False
B.
You are caring for Anastasiya Tarasova. She is counting the carbs on her lunch tray and she says she needs some insulin to sover the 50 CHO she is going to eat. How many units of insulin do you calculate she will need? a. 4 units b. 5 units c. 5.5 units d. 6 units
B. 5 units
Under the order results, Kyle Miller has a lab result: ESR = 14 mm/hr. An ESR can best be described as: a. a lab that shows how bad an infection is b. a lab that indirectly shows the degree of inflammation c. a lab that monitors the RBC count d. a lab that indirectly shows renal function and creatinine clearance
B. a lab that indirectly shows the degree of inflammation
According to Mayo Clinic, which of the following is not a goal of the telehealth or e-health modalities? a. provide access to medical specialists b. allow patients to access care who do not have health insurance coverage c. provide support for self-management of health care d. make health care accessible to people who live in rural or isolated communities
B. allows patients to access care who do not have health insurance coverage
The nurse has inserted a catheter 7.5 cm (3 inches) in a female patient and obtains no urine return even though her bladder is distended. What action should the nurse take at this time? a. remove the catheter and have another nurse attempt to catheterize the patient b. leave the catheter in the vagina as a landmark and insert another sterile catheter c. remove the catheter and reinsert into the urethra. The nurse may straighten the urethra by inserting one finger of the sterile gloved hand inside the vagina and applying gentle pressure upward d. inflate the balloon and reassess in 1 hour for urine return in the bedside drainage bag
B. leave the catheter in the vagina as a landmark and insert another sterile catheter
The nurse is assessing the patient for signs and symptoms of fluid volume excess. Which of the following would indicate the patient is experiencing this complication and should be reported? (Select all that apply.) a. Skin turgor good and capillary refill less than 3 seconds b. Decreased urine output and dry mucous membranes c. Shortness of breath and crackles in lungs d. Elevated blood pressure and edema
C, D
The nurse wishes to promote venous distention, making the vein larger and more visible for IV insertion. Which of the following measures would foster venous dilation and access to the vein? (select all that apply). a. applying a warm pack to the arm for 30 minutes b. multiple tapping of the patient's veins c. rubbing or stroking the patient's arm from distal to proximal below the proposed site d. lowering the patient's arm to a dependent position
C, D
The nursing assistive personnel, reports that the patient's gauze dressing overlying her central venous catheter is moist. This indicates a need to (select all that apply). a. reposition the the IV tubing b. flush the catheter c. check if connections are secure d. change the gauze dressing
C, D
Which of the following situations indicates catheter care should be performed? (select all that apply). a. a patient complains of bladder fullness and there is minimal urine output b. the bedside drainage bag touched the floor c. while assessing the urinary drainage system, you notice build up of secretions on the urinary catheter near the meatus d. an elderly patient is incontinent of stool e. it has been 8 hours and the patient has not received catheter care
C, D, E
A nurse is reviewing with the nursing students the differences between a straight and indwelling urinary catheter. Which of the following statements are correct descriptions related to an indwelling catheter? (select all that apply). a. a balloon is unnecessary to hold the catheter in place b. used for one-tie bladder emptying c. may remain in place for an extended epriod d. requires a health care provider's order for insertion e. requires sterile technique for insertion f. has a closed drainage system
C, D, E, F
A 40-year-old male patient has been admitted for abdominal surgery. He has no history of prostate problems. The health care provider has ordered that the patient be catheterized. Which of the following would be an appropriate size catheter for this patient? a. 8 French, 3-mL balloon b. 14 French, 5-mL balloon c. 16 French, 5-mL balloon d. 16 French, 30-mL balloon
C.
A nurse inserting an indwelling Foley catheter in a female patient advances the catheter and obtains clear yellow urine. What is the next action the nurse should take? a. Inflate the balloon with the prefilled syringe of sterile water in the balloon port. b. Pull gently back on the catheter approximately 1 inch or until resistance is met. c. Advance catheter another 1 to 2 inches and inflate balloon. d. Ask patient to bear down as if to void.
C.
A nurse is explaining the procedure for inserting an indwelling urinary catheter. Which of the following explanations regarding anchoring of the catheter, would be most accurate? a. An indwelling catheter tube is secured to a female patient's abdomen to prevent accidental dislodgment. b. An indwelling catheter tube is secured to the male's inner thigh with a strip of nonallergenic tape or a commercial tube holder. c. It is important to anchor the catheter tubing to minimize the risk for urethral trauma, bladder spasms from traction, and to prevent accidental dislodgment. d. When securing the catheter tubing, slack in the catheter should be avoided to prevent movement and possible tissue injury.
C.
Caroline never exhibits signs of either fluid volume deficit or fluid volume overload. However, upon assessing the patient's IV infusion hourly, the nurse notes the IV is running behind schedule, the site appears swollen and cool to the touch, and the patient complains of pain. What action should the nurse take? a. notify the health care provider and adjust the rate b. reduce the flow rate and notify the health care provider c. discontinue the IV and elevate the extremity d. make sure the tubing is unkinked and recalculate the flow rate
C.
It is time to change Dallas' dressing over his tunneled central venous catheter. He will be going home in a day. Which statement, if made by Dallas, indicates the need for further instruction? a. "To avoid pulling on the catheter, the old dressing should be removed in the same direction that it was inserted." b. "I should observe the exit site for any redness, drainage, or edema, and the catheter hub for intactness." c. "I clean the site first with chlorhexidine swabs, followed by alcohol swabs in a circular motion." d. "I will apply a new transparent dressing using aseptic technique every 7 days or as needed."
C.
The nurse is critiquing the changing of a dressing of a tunneled CVAD as it is being performed by another nurse. Which of the following might require feedback for correction? a. Wearing clean gloves, the nurse palpates the Dacron cuff in the subcutaneous tunnel. b. The nurse opens the dressing kit and then applies sterile gloves. c. The nurse cleans the exit site in a 3-inch area with chlorhexidine and waits 60 seconds. d. After the dressing is secure, the nurse labels the dressing with the date, time of dressing change, and initials.
C.
The nurse is preparing an IV infusion prior to initiating an IV. The nurse removes the protective sheath covering the tubing insertion spike and accidentally touches the spike. What is the nurse's best action at this time? a. Wipe the insertion spike with an alcohol swab, allow to dry, and insert into opening of IV bag. b. Insert spike into opening of IV bag and compress the drip chamber and release, allowing it to fill to one-half full. c. Discard IV tubing and obtain a new one. d. Discard IV tubing and fluids and obtain new supplies.
C.
Which of the following indicates a reason for notifying the health care provider to get an order for removal of an indwelling catheter? a. The patient states, "My bladder feels so full, it is starting to hurt!" b. The catheter has been in place for 3 days. c. The patient's urine appears cloudy with a foul odor. d. The patient is drinking less than 1500 mL of fluids daily.
C.
Regina Fields is on the standard Heparin Protocol. When first starting the heaprin, sh needs an 80 unit/kg bolus. How much heparin will she receive? a. 9600 units b. 4.36 units c. 4360 units d. 4360 mL
C. 4360 units
When performing catheter care, how many inches of the catheter will you cleanse after it exits the urinary meatus? a. 1 inch (2.5 cm) b. 2 inches (5 cm) c. 3 inches (7.5 cm) d. 4 inches (10 cm)
D
The nursing assistive personnel (NAP) is assisting the nurse to insert a Foley catheter on a male patient. In which position should the NAP place the patient? a, Sim's position b. Dorsal recumbent c. Supine with legs adducted d. Supine with legs slightly abducted.
D.
When should the tourniquet be released a second time during the procedure for insertion of a peripheral intravenous device? a. after the catheter is secured with tape or a transparent dressing b. immediately after the catheter punctures the skin c. immediately after observing a "flashback" of blood in the catheter d. after the "flashback" of blood is observed and the catheter has been advanced off the stylet
D.
Which would be an appropriate expected outcome of this diagnosis? a. Assess patient's reaction to vascular access device and ability to discuss steps in care. b. Site is intact without redness, swelling, tenderness, or exudate when device is in place. c. Patient's white blood cell count is within normal limits; patient is afebrile. d. Patient is able to demonstrate dressing change and skin care of device by discharge.
D.
While changing Dallas' dressing, the nurse observes his condition. Which data obtained by the nurses indicates a potential complication requiring follow-up? a. Temperature 36.9°C (98.4 °F), pulse 80, respirations 16 b. Previous dressing was dry and intact with scant amount of old blood noted. c. Dacron cuff palpable d. Dallas states it is tender as you remove the old dressing. The site is red without exudate.
D.
How frequently should a transparent occlusive dressing on a central venous access device be changed? a. every 24 hours and as needed b. every 48 hours and as needed c. every 3 days and as needed d. every 5-7 days and as needed
D. every 5-7 days and as needed
All of the following are medications that could be given to a patient in pre-term labor to stop contractions, except: a. terbutaline b. magneisum sulfate c. indocin d. pitocin
D. pitocin
In communication with a new patient or client, the orientation phase occurs first. All of the following are goals in the orientation phase, except: a. to establish trust b. to instill hope and ensure that the patient will remain adherent to treatment c. to develop appropriate goals (outcome criteria) and a plan of care d. promoting the patient's problem-solving ability
D. promoting the patient's problem-solving ability
The nursing assistive personnel (NAP) is assisting the nurse to insert a Foley catheter on a male patient. In which position should the NAP place the patient? a. Sim's position b. dorsal recumbent c. supine with legs adducted d. supine with legs slightly abducted
D. supine with legs slightly abducted
Betamethasone can be given to a woman at risk for pre-term labor, orally or intramuscularly. True or False
False
Registered nurses using videoconferencing to provide education to patients is not considered a form of Telehealth. True or False
False
Resistance during catheter insertion with a male is always a sign of urethral obstruction. a. True b. False
False
Standing directly over a patient in the bed is an appropriate position for the nurse to engage in therapeutic communication form. True or False
False
The catheter should be inserted at least 17 cm into the urethra of the female patient. a. True b. False
False
This patient's abdominal discomfort could be due in part to bladder distention as well as her surgery. a. True b. False
False
Determine if the patient is experiencing a fluid volume deficit or fluid volume excess: a. increase in blood pressure b. distended neck veins c. abnormal lung sounds d. thirst e. decreased skin turgor f. decreased urine output g. decrease in blood pressure h. behavioral changes i. increase in daily weight by 1 kg j. peripheral edema k. dry skin and mucous membranes
a. FVE b. FVE c. FVE d. FVD e. FVD f. FVD g. FVD h. FVD i. FVE j. FVE k. FVD
