PPNC 2
A client is admitted to a surgical unit postoperatively with a wound drain in place. Which actions would the nurse take in the care of the drain? Select all that apply. A. Check the drain for patency. B. Observe for bright red bloody drainage. C. Clamp the drain for 15 minutes every hour. D. Curl the drain tightly, and tape it firmly to the body. E. Maintain aseptic technique when emptying the drain.
A,B ,E Rationale:The nurse would check the tube or drain for patency to provide an exit for the fluid or blood to promote healing. The nurse would monitor the drainage characteristics. Usually the drainage from the wound is pale, red, and watery. Active bleeding will be bright red. The nurse must use aseptic technique for emptying the drainage container or changing the dressing to avoid contamination of the wound. A postoperative drain would not be curled tightly or obstructed in any way, such as with clamping. This could prevent the drain from functioning properly.
The nurse is caring for a 1-day postoperative client who is complaining of urinary retention. What are the initial assessment techniques or interventions the nurse would employ? Select all that apply. A.Palpation B.Inspection C. Percussion D.Auscultation E.Bladder scanner F.Insertion of Foley catheter
A,B,C, E Rationale:Control of urination may return immediately after surgery or may not return for hours after general or regional anesthesia. The effects of preoperative medications (especially atropine), anesthetic agents, or manipulation during surgery can cause urine retention. Assessment may be difficult to perform after lower abdominal surgery. Assess for urinary retention by inspection, palpation, and percussion of the lower abdomen for bladder distention or by the use of a bladder scanner. Auscultation and inserting a Foley catheter are not interventions for initial postoperative urinary problems.
The nurse is caring for a client who needs a hypertonic intravenous (IV) solution. What solutions are hypertonic? Select all that apply. A.10% dextrose in water B. 0.45% sodium chloride C.5% dextrose in 0.9% saline D.5% dextrose in 0.45% saline E.5% dextrose in 0.225% saline F.5% dextrose in lactated Ringer's solution
A,C,D,F
The nurse receives a telephone call from the postanesthesia care unit stating that a client who had abdominal surgery is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client? A. Assess the patency of the airway. B.Check tubes or drains for patency. C.Check the dressing to assess for bleeding. D.Assess the vital signs to compare with preoperative measurements.
A. Assess the patency of the airway. Rationale:The first action of the nurse is to assess the patency of the airway and respiratory function. If the airway is not patent, the nurse must take immediate measures for the survival of the client. The nurse then takes vital signs followed by checking the dressing and the tubes or drains. The other nursing actions would be performed after a patent airway has been established.
The nurse determines that a client with a tracheostomy tube needs suctioning if which finding is noted? A. Rhonchi are auscultated. B.Pleural friction rub is heard. C.Fine crackles are auscultated. D. Pulse oximetry reading is 96%.
A. Rhonchi are auscultated. Rationale:The presence of rhonchi is an indication that there are secretions in the large airways. The client requires suctioning if the client cannot expectorate them. A pulse oximetry reading of 96% is an acceptable reading. A pleural friction rub is indicative of inflamed pleural surfaces. Fine crackles are indicative of air moving into previously deflated alveoli.
During an assessment of a newly admitted client, the nurse notes that the client's heart rate is 110 beats/min, his blood pressure shows orthostatic changes when he stands up, and his tongue has a sticky, pastelike coating. The client's spouse tells the nurse that he seems a little confused and unsteady on his feet. Based on these assessment findings, the nurse suspects that the client has which condition? A.Dehydration B.Hypokalemia C. Fluid overload D. Hypernatremia
A.Dehydration
A client has a wound with a moderate amount of drainage and is scheduled for a dressing change. Which dressing, if selected by the student nurse, requires further intervention by the nursing instructor? A. Foam B. Alginate dressing C. Hydrocolloid dressing D. Semipermeable transparent film
D. Semipermeable transparent film Rationale:The client's wound has moderate drainage. Recall that foam, alginate, and hydrocolloid dressings are applied to wounds with moderate to heavy drainage. Semipermeable transparent films are applied to dry wounds.
The nurse cares for a client who is at risk for wound dehiscence after abdominal surgery. Which action is the priority to minimize this risk? A. Administer prescribed antibiotics. B. Use sterile technique for dressing changes. C. Keep sterile saline and sterile dressings at the bedside. D.Place a pillow over the incision site during deep breathing and coughing.
D.Place a pillow over the incision site during deep breathing and coughing.
In preparation for ambulation, the nurse is planning to assist a postoperative client to progress from a lying position to a sitting position. Which nursing action is appropriate to maintain the safety of the client? A. Assess the client for signs of dizziness and hypotension. B. Allow the client to rise from the bed to a standing position unassisted. C. Elevate the head of the bed quickly to assist the client to a sitting position. D. Assist the client to move quickly from the lying position to the sitting position.
A. Assess the client for signs of dizziness and hypotension.
Precautions are used when caring for a client with Clostridium difficile. The nurse is planning on providing morning care for the client and needs to obtain which specific protective equipment for this infection? A. Gloves and a gown B. Gloves and a mask C. Gloves, gown, and a mask D. Gloves, gown, mask, and a hair covering
A. Gloves and a gown Rationale:Clostridium difficile (C. diff) is an infection that destroys normal bowel flora and leads to increased diarrhea. Contact precautions are used for clients with Clostridium difficile because the infection is in the stool. With contact precautions, the nurse needs to wear gloves and a gown to provide protection from the infection. A mask is not necessary unless another condition that is transmitted via the droplet or airborne routes is present, or if agency policy and procedure mandates the use of a mask.
The nurse is caring for a client with a diagnosis of severe dehydration. The client has been receiving intravenous (IV) fluids and nasogastric (NG) tube feedings. The nurse monitors fluid balance using which as the best indicator? A.Daily weight B.Urinary output C.IV fluid intake D.NG tube intake
A.Daily weight Rationale:Daily weight is the best indicator of fluid balance. Options 2, 3, and 4 are related to intake or output but are incomplete indicators of fluid balance.
The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour? A.Urinary output of 20 mL/hr B. Temperature of 37.6° C (99.6° F) C. Blood pressure of 100/70 mm Hg D. Serous drainage on the surgical dressing
A.Urinary output of 20 mL/hr Rationale:Urine output needs to be maintained at a minimum of 30 mL/hr for an adult. An output of less than 30 mL for 2 consecutive hours needs to be reported to the primary health care provider. A temperature higher than 37.7° C (100° F) or lower than 36.1° C (97° F) and a falling systolic blood pressure, lower than 90 mm Hg, are usually considered reportable immediately. The client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. Moderate or light serous drainage from the surgical site is considered normal
The nurse is preparing to suction a client via a tracheostomy tube. The nurse would plan to limit the suctioning time to a maximum of which time period? A.5 seconds B.10 seconds C. 30 seconds D. 60 seconds
B Rationale:Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker cells in the heart. A vasovagal response may occur, causing bradycardia. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to 10 seconds.
When a client is transferred from the postanesthesia care unit and arrives on the surgical unit, which would be the first action taken by the nurse? A. Assess the client's pain. B.Obtain the client's vital signs. C.Administer oxygen to the client. D.Check the rate of the intravenous infusion.
B.Obtain the client's vital signs.
Two nurses are leaving the room of a client whose care required them to wear a gown, mask, and gloves. Which action by these nurses could lead to the spread of infection? A.Taking off the gloves first before removing the gown B.Removing the gown without rolling it from inside out C.Washing the hands after the entire procedure has been completed D.Removing the gloves and then removing the gown using the neck ties
B.Removing the gown without rolling it from inside out Rationale:The gown must be rolled from inside out to prevent the organisms on the outside of the gown from contaminating other areas. Gloves are considered the dirtiest piece of equipment and therefore must be removed first. Hands must be washed after removal of the protective garb to remove any unwanted germs still present. Ungloved hands need to be used to remove the gown to prevent contaminating the back of the gown with germs from the gloves.
The nurse is assessing a client who had abdominal surgery earlier in the day. Which preexisting medical condition would place the client at most risk for postoperative complications? A. Pacemaker B. Osteoporosis C. Alcohol abuse D. Peptic ulcer disease
C. Alcohol abuse Rationale:A client with a history of alcohol abuse is at risk for liver disease, including altered metabolism and elimination of medications, impaired wound healing, and clotting and bleeding abnormalities. A client with this risk factor also would be at risk for experiencing alcohol withdrawal during the postoperative period. Clients with a pacemaker, osteoporosis, and peptic ulcer disease need to be monitored closely but are not at risk for major complications, as is the client with alcohol abuse and liver disease
The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? A.Weight loss and dry skin B.Flat neck and hand veins and decreased urinary output C. An increase in blood pressure and increased respirations D. Weakness and decreased central venous pressure (CVP)
C. An increase in blood pressure and increased respirations Rationale:A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. Dry skin, flat neck and hand veins, decreased urinary output, and decreased CVP are noted in fluid volume deficit. Weakness can be present in either fluid volume excess or deficit.
The client complains of pain as the nurse is inflating the balloon during insertion of a Foley catheter. The nurse would take which immediate action? A. Withdraw the catheter slightly and reinflate the balloon. B.Remove the catheter, and reinsert a new one that is 1 size smaller. C.Finish inflating the balloon; the discomfort is normal and temporary. D.Aspirate the fluid, advance the catheter farther, and reinflate the balloon.
D.Aspirate the fluid, advance the catheter farther, and reinflate the balloon. Rationale:If the balloon is malpositioned in the urethra, balloon inflation could cause trauma and pain. If this occurs, the fluid needs to be aspirated and the catheter inserted a little farther to move the balloon past the neck of the urethra into the bladder. The catheter would not be withdrawn slightly because this will worsen the problem. There is no need to remove the catheter and reinsert a smaller one. The balloon would not continue to be inflated because the pain is not normal and will not go away.
Contact precautions are initiated for a client with a nosocomial (health care-associated) infection caused by methicillin-resistant Staphylococcus aureus. The nurse prepares to provide colostomy care and would obtain which protective items to perform this procedure? A.Gloves and gown B.Gloves and goggles C. Gloves, gown, and shoe protectors D.Gloves, gown, goggles, and a mask or face shield
D.Gloves, gown, goggles, and a mask or face shield Rationale:Splashes of body secretions can occur when providing colostomy care. Goggles and a mask or face shield are worn to protect the face and mucous membranes of the eyes during interventions that may produce splashes of blood, body fluids, secretions, or excretions. In addition, contact precautions require the use of gloves, and a gown should be worn if direct client contact is anticipated. Shoe protectors are not necessary.
The nurse is monitoring the fluid balance of a client with a burn injury. The nurse determines that the client is less than adequately hydrated if which information is noted during assessment? A.Urine pH of 6 B.Urine that is pale yellow C.Urine output of 40 mL/hr D.Urine specific gravity of 1.032
D.Urine specific gravity of 1.032 Rationale:The client who is not adequately hydrated will have an elevated urine specific gravity. Normal values for urine specific gravity range from approximately 1.005 to 1.030. Pale yellow urine is a normal finding, as is a urine output of 40 mL/hr (minimum is 30 mL/hr). A urine pH of 6 is adequate (4.6 to 8.0 normal), and this value is not used in monitoring hydration status.
The nurse is planning care for a client who is scheduled for a tracheostomy procedure. What equipment would the nurse plan to have at the bedside when the client returns from surgery? A.Obturator B. Oral airway C. Epinephrine D. Tracheostomy set with the next larger size
Obturator Rationale:A replacement tube of the same size and an obturator are kept at the bedside at all times in case the tracheostomy tube becomes dislodged. In addition, a curved hemostat that could be used to hold the trachea open if dislodgment occurs needs to be kept at the bedside. An oral airway and epinephrine would not be needed.
The nurse is preparing to suction the airway of a client who has a tracheostomy tube and gathers the supplies needed for the procedure. In order of priority, which actions would the nurse take to perform this procedure? Arrange the actions in the order that they would be performed. All options must be used. 1. Hyperoxygenate the client. 2.Place the client in a semi-Fowler's position. 3.Attach the suction tubing to the suction catheter. 4.Turn on the suction device and set the regulator at 80 mm Hg. 5.Insert the catheter into the tracheostomy until resistance is met, and then pull it back 1 cm 6.Apply intermittent suction and slowly withdraw the catheter while rotating it back and forth.
2 Place the client in a semi-Fowler's position. 4 Turn on the suction device and set the regulator at 80 mm Hg. 3 Attach the suction tubing to the suction catheter. 1 Hyperoxygenate the client 5 .Insert the catheter into the tracheostomy until resistance is met, and then pull it back 1 cm 6 Apply intermittent suction and slowly withdraw the catheter while rotating it back and forth.
Which interventions are essential to perform when a central venous site is suspected of being infected? Select all that apply. A. Prepare to administer antibiotics. B. Notify the primary health care provider (PHCP). C. Inform the client that blood cultures will need to be obtained. D. Document the occurrence, the actions taken, and the client's response. E. Continue to use the central venous catheter until another one is placed.
A,B,C,D Rationale:Signs of infection at the catheter site include redness or drainage. The client will also exhibit chills, fever, and an elevated white blood cell count. If the nurse suspects infection, the PHCP is notified because of the risk for sepsis. The catheter is removed, and the client is prepared for a possible restart at a different location as prescribed. A central line may be removed by a nurse who has been trained in approved protocol to remove a central line. If requested, the catheter tip may be sent to the laboratory for culture to identify the bacteria present so that the effective antibiotic is prescribed. Intravenous (IV) antibiotics may be prescribed, and an IV site will be needed for administration. Blood cultures are also performed to determine the presence of bacteria in the blood. Antibiotics are not started until blood cultures are obtained; otherwise, the results of the cultures may be inaccurate. Finally, the nurse documents the occurrence, actions taken, and the client's response. Additionally, per agency protocol, pictures of the infected catheter site may be taken and added to the documentation.
Which would the nurse do when caring for a client with a chest tube attached to a chest drainage system? A.Empty the drainage collection chamber every shift. B.Ensure the water level in the water seal chamber is at the 2-cm level. C.Maintain the drainage collection device at the level of the client's chest. D.Clamp the chest tube before moving the client from the bed to the chair.
B.Ensure the water level in the water seal chamber is at the 2-cm level. Rationale:The water seal chamber acts as a one-way valve. It allows air and fluid to leave the pleural space but prevents reentry of atmospheric air. The minimum amount needed is 2 cm of water. A closed chest drainage system must remain airtight at all times. The device is kept below the level of the chest. If the device is kept at the level of the chest, there can be backflow of drainage into the pleural cavity. A chest tube would not be clamped unless specifically prescribed.
The nurse has completed care for a client whose tracheostomy tube has a nondisposable inner cannula. Which action would the nurse perform prior to reinserting the inner cannula? A.Suction the client's airway. B. Wipe the inner cannula off with a clean washcloth. C. Dry the inner cannula thoroughly with sterile gauze. D.Allow the inner cannula to dry after washing it with sterile water.
D. Allow the inner cannula to dry after washing it with sterile water. Ratonale: After washing the inner cannula with half strength peroxide and rinsing it with sterile water (per agency policy), the nurse taps it against a sterile surface to remove excess liquid and allows it to dry. The nurse then inserts the cannula into the tracheostomy tube and turns it clockwise to lock it in place. The nurse would not suction a client without an inner cannula in place. This is a sterile procedure; therefore, it is inaccurate to use a clean washcloth. Gauze is not used to dry the cannula because gauze particles can remain on the cannula.
The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal compartment. Which is the most appropriate action? A. Check for an air leak. B. Document the findings. C. Change the chest tube drainage system. D. Notify the primary health care provider (PHCP).
Document the findings. Rationale:Bubbling in the water seal compartment is caused by air passing out of the pleural space into the fluid in the chamber. Intermittent bubbling is normal. It indicates that the system is accomplishing one of its purposes, removing air from the pleural space. Therefore, it is unnecessary to call the PHCP or change the chest tube drainage system. Continuous bubbling during inspiration and expiration indicates an air leak. If this occurs, it must be corrected.
The nurse is caring for a client with meningitis and implements which transmission-based precautions for this client? A. private room B. Personal respiratory protection device C.Private room with negative airflow pressure D. Mask worn by staff when the client needs to leave the room
A. private room Rationale:Meningitis is transmitted by droplet infection. Precautions for this disease include a private room or cohort (as appropriate) client and use of a standard precaution mask. Private negative airflow pressure rooms and personal respiratory protection devices are required for clients with airborne disease such as tuberculosis. When appropriate, a mask must be worn by the client and not the staff when the client leaves the room
The nurse is caring for an abdominal surgical client who has a Jackson-Pratt drain in place. Which interventions would the nurse include in the plan of care for this drain? Select all that apply. A. Secure the drain to the sheet. B. Make sure suction is maintained. C. Check that the drains are sutured in place. D.Use clean technique to empty the reservoir. E. Compress the reservoir to restore suction after emptying. F. Record the amount and color of drainage according to agency protocol or surgeon's prescription.
B,C,E, F Rationale:Interventions include making sure suction is maintained, checking that the drains are sutured in place, compressing the reservoir to restore suction after emptying, and recording the amount and color of drainage according to agency protocol or surgeon's prescription. The other interventions are not appropriate
The nurse in a surgical unit receives a postoperative client from the postanesthesia care unit. After the initial assessment of the client, the nurse would plan to continue with postoperative assessment activities how often? A. Every hour for 2 hours and then every 4 hours as needed B. Every 30 minutes for the first hour, every hour for 2 hours, and then every 4 hours as needed C. Every 15 minutes for the first hour, every 30 minutes for 2 hours, every hour for 4 hours, and then every 4 hours as needed D. Every 5 minutes for the first half-hour, every 15 minutes for 2 hours, every 30 minutes for 4 hours, and then every hour as needed
C. Every 15 minutes for the first hour, every 30 minutes for 2 hours, every hour for 4 hours, and then every 4 hours as needed
The nurse has a prescription to remove the nasogastric (NG) tube from a client on the first postoperative day after cardiac surgery. The nurse would question the prescription if which finding was noted on assessment of the client? A. The client is drowsy. B. Bowel sounds are absent. C. The abdomen is slightly distended. D.NG tube drainage is Hematest negative.
B. Bowel sounds are absent. Rationale:The NG tube would remain in place until the client has bowel sounds. If NG suction is being used, the nurse needs to turn off the suction before listening to bowel sounds to prevent mistaking the sound of the suction for bowel sounds. If bowel sounds do not return, the client could have a paralytic ileus, which could result in distention and vomiting if the NG tube is discontinued. It is likely that the client would be drowsy after experiencing a stressor such as cardiac surgery. The abdomen is likely to be slightly distended after surgery, and it is normal for NG tube drainage to be Hematest negative
A hydrocolloid dressing is prescribed for a client with a leg ulcer. The home health nurse is preparing a plan of care for the client and would appropriately document which intervention? A. Change the hydrocolloid dressing daily. B. Change the hydrocolloid dressing every 3 to 5 days. C. Apply the hydrocolloid dressing over a dry, sterile dressing. D. Apply the hydrocolloid dressing over a normal saline-soaked dressing.
B. Change the hydrocolloid dressing every 3 to 5 days. Rationale:A hydrocolloid dressing contains hydroactive particles embedded in a polymer base that are softened by wound moisture and act as a protective gel over healing tissue. It is applied directly to the wound and needs to be changed every 3 to 5 days (or more frequently if drainage from the wound is excessive). It is not applied over a dry, sterile dressing or a normal saline-soaked dressing because it then would not be able to act as a protective gel.
The nurse is caring for a group of clients on the clinical nursing unit. Which client would the nurse plan to monitor for signs of fluid volume deficit? A.Client in heart failure B.Client in acute kidney injury C. Client with an ileostomy D. Client with controlled hypertension
C. Client with an ileostomy Rationale:The client with an ileostomy is at risk for fluid volume deficit caused by increased gastrointestinal tract losses. Other causes of fluid volume deficit include vomiting, diarrhea, conditions that cause increased respiratory rate or urine output such as diabetes insipidus, insufficient intravenous fluid replacement, and draining fistulas. Clients who have heart failure or kidney disease are at risk for fluid volume excess. Hypertension may be associated with fluid volume excess.
The nurse is creating a plan of care for a client scheduled for surgery. The nurse would include which activity in the nursing care plan for the client on the day of surgery? A. Avoid oral hygiene and rinsing with mouthwash. B. Verify that the client has not eaten for the last 24 hours. C. Have the client void immediately before going into surgery. D. Report immediately any slight increase in blood pressure or pulse.
C. Have the client void immediately before going into surgery. Rationale:The nurse would assist the client to void immediately before surgery so that the bladder will be empty. Oral hygiene is allowed, but the client should not swallow any water. The client usually has a restriction of food and fluids for 6 to 8 hours (or longer depending on the procedure and as prescribed) before surgery instead of 24 hours. A slight increase in blood pressure and pulse is common during the preoperative period and is usually the result of anxiety.
The nurse has instructed a preoperative client using an incentive spirometer to sustain the inhaled breath for 3 seconds. When the client asks about the rationale for this action, the nurse explains that this action achieves which function? A. Dilates the major bronchi B. Increases surfactant production C. Maintains inflation of the alveoli D. Enhances ciliary action in the tracheobronchial tree
C. Maintains inflation of the alveoli Rationale:Sustained inhalation helps maintain inflation of terminal bronchioles and alveoli, thereby promoting better gas exchange. Routine use of devices such as an incentive spirometer can help prevent atelectasis and pneumonia in clients at risk for these conditions.
The nurse would determine that tracheal suctioning is needed if which is noted? A. Arterial oxygen level of 90 mm Hg B.2 hours elapsed since the last suctioning C.Congested breath sounds in the lung fields D. Respiratory rate of 18 breaths/min, up from 16 breaths/min
C.Congested breath sounds in the lung fields Rationale:Suctioning is indicated only when the client has adventitious breath sounds or has accumulation of secretions. It is not performed routinely according to time elapsed since the last suctioning (2 hours elapsed since the last suctioning). Arterial blood gas results and respiratory rate (arterial oxygen level of 90 mm Hg and respiratory rate of 18 breaths/min, up from 16 breaths/min) are not good indicators of the need for suctioning because they may be influenced by a number of other factors in addition to the need for suctioning.
A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions would the nurse take? Select all that apply. A.Contact the surgeon. B. Instruct the client to remain quiet. C. Prepare the client for wound closure. D. Document the findings and actions taken. E. Place a sterile saline dressing and ice packs over the wound. F.Place the client in a supine position without a pillow under the head.
A,B,C
The nurse is preparing a client for surgery scheduled in 2 hours. Which interventions are appropriate in the preoperative period? Select all that apply. A. Assist the client to void before transfer to the operating room. B. Check all surgeon's prescriptions to ensure that they have been carried out. C. Teach postoperative breathing exercises before the client is premedicated. D. Review the client's record for a history and physical report and laboratory reports. E. Administer all the daily medications 2 hours before the scheduled time of the surgery.
A,B,D Rationale:The nurse would assist the client to void before transfer to the operating room, if a Foley catheter is not in place. The nurse also checks the surgeon's prescriptions to ensure that they have been carried out; if a prescription has not been carried out, the nurse would have the time to ensure that it is. Two hours before the scheduled surgery time is not the time to teach breathing exercises. This would have been accomplished earlier. A history and physical needs to be in the record so that all primary health care providers involved in the surgical procedure will be familiar with the client's health status. Additionally, the results of any laboratory tests prescribed need to be documented. The nurse does not administer all daily medications. Rather, the primary health care provider writes a specific prescription outlining which medications may be given with a sip of water.
The nurse is reviewing the blood tests of a generally healthy client who is scheduled for orthopedic surgery under general anesthesia. Besides a complete blood count (CBC), what preadmission blood tests would the preoperative nurse expect to be prescribed? Select all that apply. A. D-dimer assay B. Clotting studies C. Glucose fasting D. Electrolyte levels E. Arterial blood gas (ABG) F. Serum creatinine and blood urea nitrogen (BUN) levels
B,C,D,F Rationale:The most common blood tests prescribed preoperatively include CBC, clotting studies, glucose fasting, electrolyte levels, and serum creatinine and BUN levels. A urinalysis is also prescribed. Preoperative blood tests do not include ABG and D-dimer assay. Clotting studies must be prescribed to determine whether the surgical client may experience major hemorrhage from prolonged bleeding or clotting times. Glucose fasting must be done because many forms of stress such as general anesthesia can cause increased serum glucose levels. Electrolyte imbalances such as potassium levels (both increased and decreased) can affect the cardiac system, leading to dysrhythmias, especially with the use of anesthesia. Any potassium imbalance—hypokalemia or hyperkalemia—must be corrected before surgery. Serum creatinine and BUN levels must be assessed to determine any underlying renal disease that could be compounded with surgery.
An assistive personnel (AP) is caring for a client who has an indwelling urinary catheter. Which action by the AP would indicate the need for further instruction in the care of the client? A. Used soap and water to cleanse the perineal area B. Allowed the drainage tubing to rest under the leg C. Kept the drainage bag below the level of the bladder D. Used the drainage tubing port to obtain urine samples
B. Allowed the drainage tubing to rest under the leg Rationale:Proper care of an indwelling urinary catheter is especially important to prevent infection in the client. The drainage tubing is not placed under the client's leg; for the same reason, the drainage bag is kept below the level of the bladder to prevent urine from being trapped in the bladder. The tubing must drain freely at all times. The perineal area is cleansed thoroughly, using mild soap and water at least twice a day and following a bowel movement. The nurse and all caregivers must use strict aseptic technique when emptying the drainage bag or obtaining urine specimens.
The nursing instructor is observing a student nurse donning a pair of sterile gloves and preparing a sterile field. Which observation made by the instructor indicates the need for further teaching? A. The student puts on the right glove and then the left glove. B. The student dons the sterile gloves without washing the hands. C. The student uses the inner wrapper of the gloves as a sterile field. D. The student touches a glove on the overbed table, removes both gloves, and dons another sterile pair.
B. The student dons the sterile gloves without washing the hands. Rationale:Hands must always be washed (even though sterile gloves are used) to keep germs from spreading. The order of placing gloves on is up to the user, as long as sterile technique is not broken. The inside wrapper provides an excellent area for use because it is sterile. If the gloves touch anything unsterile, they must be considered contaminated, and a new package of gloves must be obtained and used.
The nurse is caring for a client with a diagnosis of dehydration, and the client is receiving intravenous (IV) fluids. Which assessment finding would indicate to the nurse that the dehydration remains unresolved? A. An oral temperature of 98.8° F (37.1° C) B.A urine specific gravity of 1.043 C. A urine output that is pale yellow D.A blood pressure of 120/80 mm Hg
B.A urine specific gravity of 1.043 Rationale:The client who is dehydrated will have a urine specific gravity greater than 1.030. Normal values for urine specific gravity are 1.003 to 1.030. A temperature of 98.8° F (37.1° C) is only 0.2 of a point above the normal temperature and would not be as specific an indicator of hydration status as the urine specific gravity. Pale yellow urine is a normal finding. A blood pressure of 120/80 mm Hg is within normal range.
The nurse is inserting an indwelling urinary catheter. As the catheter is inserted into the urethra, urine begins to flow into the tubing. What would the nurse do next? A.Immediately twist the catheter, and then slowly inflate the balloon. B.Insert the catheter 2.5 to 5 cm farther, and then inflate the balloon. C.Insert the catheter until resistance is met, and then inflate the balloon. D.Withdraw the catheter approximately 1 in (2.5 cm), and then inflate the balloon.
B.Insert the catheter 2.5 to 5 cm farther, and then inflate the balloon. Rationale:The balloon is behind the opening at the catheter tip. The catheter is inserted 7 to 9 in (18 to 23 cm) after urine begins to flow, providing sufficient space to inflate the balloon and ensuring that the balloon has passed through the entire urethra and into the bladder. Inflating the balloon in the urethra could produce trauma.
The nurse is caring for a client with a wound infected with methicillin-resistant Staphylococcus aureus (MRSA). The most appropriate infection control precautions for MRSA include which intervention? A.Room with positive-pressure airflow B.Private room, gown, gloves, and face shield C.Private room with negative-pressure airflow D. Mask or respiratory protection device and gown
B.Private room, gown, gloves, and face shield Rationale:Isolation guidelines from the Centers for Disease Control and Prevention (CDC) place MRSA at the tier 2 transmission category. Contact precautions are required and include a private room, gloves, gowns, and face shields in case a splash from the wound drainage occurs, such as with wound irrigation. A room with negative-pressure airflow is required for airborne precautions from small droplet infections such as measles, chicken pox, or tuberculosis. A respiratory protection device is recommended for larger droplet infections such as pneumonia. A room with positive-pressure airflow is recommended for protective environments such as those required for clients with stem cell transplants.
The nurse is providing preoperative teaching to a client scheduled for a laparoscopic cholecystectomy. Which intervention would be of highest priority in the preoperative teaching plan? A. Teaching leg exercises B.Teaching coughing and deep-breathing exercises c. Providing in structions regarding food and fluid restrictions D. Assessing the client's understanding of the surgical procedure
B.Teaching coughing and deep-breathing exercises Rationale:After cholecystectomy, respirations tend to be shallow because deep breathing is painful as a result of the location for the surgical procedure. Although all the options are correct, teaching coughing and deep-breathing exercises is the highest priority.
The nurse is monitoring a client who has a closed chest tube drainage system. The nurse notes fluctuation of the fluid level in the water seal chamber during inspiration and expiration. On the basis of this finding, the nurse would make which interpretation? A.There is a leak in the system. B.The chest tube is functioning as expected. C.The amount of suction needs to be decreased. D.The occlusive dressing at the insertion site needs reinforcement.
B.The chest tube is functioning as expected. Rationale:The presence of fluctuation of the fluid level in the water seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, if the suction is not working properly, or if the lung has reexpanded. Options 1, 3, and 4 are incorrect interpretations of the finding. An air leak may cause excessive bubbling in the water seal chamber. Excessive and vigorous bubbling in the suction control chamber may indicate that the amount of suction needs to be decreased. The status of the dressing is not specifically related to the presence of fluctuation of the fluid level in the water seal chamber.
The nurse is assisting a client to collect a midstream urine specimen. How would the nurse implement aseptic technique? A. Cleansing the meatus with antiseptic pads using upward strokes B. Letting go of the labia once this tissue is cleansed to allow the client to urinate C. Making sure that the fingers avoid touching the inside of the collection container D. Instructing the client to urinate in the container after the labia have been cleansed
C. Making sure that the fingers avoid touching the inside of the collection container Rationale:The inside of the container is sterile, and sterility must be maintained. Fingers touching the inside of the container would cause the container to become unsterile. The meatus would be cleansed from front to back (toward the anus). Upward strokes would bring bacteria from the anal region toward the urinary meatus. The labia would remain open during the procedure. If they are allowed to close, this tissue will have to be cleansed again with the antiseptic pads. The client would void a small amount into the toilet before urinating into the specimen container to allow some of the organisms near the meatus to leave the area.
The nurse is performing nasotracheal suctioning of a client. The nurse determines that the client is tolerating the procedure if which observation is made? A.The skin color becomes cyanotic. B.Secretions are becoming bloody. C.Coughing occurs with suctioning. D.Heart rate decreases from 78 to 54 beats/minute.
C.Coughing occurs with suctioning. Rationale:The nurse monitors for adverse effects of suctioning, which include cyanosis, excessively rapid or slow heart rate, and sudden development of bloody secretions. If any of these signs is observed, the nurse immediately stops suctioning and reports the adverse effect to the primary health care provider. Coughing is a normal response to suctioning for the client with an intact cough reflex and does not indicate that the client cannot tolerate the procedure.
A client with pulmonary tuberculosis (TB) is on airborne isolation precautions. Which item(s) is essential for the nurse to wear? A. Gloves only B. Fluid shield mask C. Gown, mask, and gloves D. High-efficiency particulate air (HEPA) filter mask
D. High-efficiency particulate air (HEPA) filter mask Rationale:The hospitalized client with TB is placed on airborne isolation. A HEPA filter mask must be worn whenever the nurse enters the client's room because these masks can remove almost 100% of the small TB particles. This mask must fit snugly around the nose and mouth. Option 1 is an incorrect option; although gloves may be needed, the nurse must wear a HEPA mask. Option 2 is incorrect. The mask must be a HEPA mask. Option 3 is an incorrect choice. The mask must be a HEPA mask, and there is no need for gown and gloves unless a wound, body fluid, or blood is involved.
A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse would take which most appropriate action in the care of this client? A. Obtain a court order for the surgery. B. Have the charge nurse sign the informed consent immediately. C. Send the client to surgery without the consent form being signed. D. Obtain a telephone consent from a family member, following agency policy.
D. Obtain a telephone consent from a family member, following agency policy. Rationale:Every effort would be made to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent form. A telephone consent must be witnessed by two persons who hear the family member's oral consent. The two witnesses then sign the consent with the name of the family member, noting that an oral consent was obtained. Consent is not informed if it is obtained from a client who is confused, unconscious, mentally incompetent, or under the influence of sedatives. In an emergency, a client may be unable to sign and family members may not be available. In this situation, a primary health care provider is permitted legally to perform surgery without consent, but the data in the question do not indicate an emergency. Options 1, 2, and 3 are inappropriate in this situation. Also, agency policies regarding informed consent would always be followed.
The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse would include which piece of information in discussions with the client? A. Inhale as rapidly as possible. B. Keep a loose seal between the lips and the mouthpiece. C. After maximum inspiration, hold the breath for 15 seconds and exhale. D.The best results are achieved when sitting up or with the head of the bed elevated to 45 to 90 degrees
D.The best results are achieved when sitting up or with the head of the bed elevated to 45 to 90 degrees Rationale:For optimal lung expansion with the incentive spirometer, the client would assume the semi-Fowler's or high-Fowler's position. Clients who are obese need to be taught to use the reverse Trendelenburg or side-lying position because they are able to move their diaphragm better in these positions. The mouthpiece would be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. The breath needs to be held for 5 seconds before exhaling slowly.
