PPNC2- EAQ's for Exam 1
Which food or drink would the nurse instruct a client with a new colostomy to avoid because it produces large amounts of gas?
Cabbage
Which assessment finding would the nurse report to the HCP when giving immediate postoperative care to a client with a newly placed ostomy?
Blanching, dark red to purple color of stoma
A client with a newly formed colostomy, secondary to cancer of the rectum, received instructions regarding ostomy care and management. Which client statement indicates understanding of colostomy care?
"I will call the clinic and report if I have difficulty inserting the irrigating tube into the into the stoma"
An IV line is inserted in the scalp vein of an infant. The parents ask why the IV is not placed in the hand. Which response by the nurse is most appropriate?
"Usually veins in the arm or hand are used, but your baby's were too small"
When teaching a client with a new colostomy about appliance care and maintenance, which information would the nurse include? Select all that apply
-Change the ostomy pouch on a routine basis -Replace the ostomy wafer weekly or sooner as needed -Empty the ostomy pouch before exercise and at bedtime
Which nursing intervention would the nurse implement for client safety and quality of care when placing a short peripheral venous catheter? Select all that apply.
-Choose a distal site -Do not use the arm on the side of a mastectomy -Choose a vein of appropriate length and width to fit the catheter's size
The nurse is preparing to insert an IV catheter to a thin, emaciated client who is scheduled to begin IV fluid therapy. Which interventions would the nurse follow to provide high quality care? Select all that apply.
-Flush the IV line with normal saline -Stop the insertion procedure where there is a break in technique
Which clinical manifestation would the nurse identify as an indicator suggesting a client has urinary retention and overflow after sustaining a cerebrovascular accident (CVA, also known as a "brain attack")?
-Frequent voiding -Suprapubic distention
Which nursing action during a focused urinary assessment would the nurse use to collect subjective client data? Select all that apply.
-Inquire about painful urination -Ask the client about changes in characteristics of urination
Which clinical indicator would the nurse expect when an IV line has infiltrated? Select all that apply.
-Pallor -Edema -Decreased flow rate
A client is to receive a transfusion of packaged red blood cells (PRBCs). Which solution would the nurse use to prime the blood intravenous (IV) tubing?
0.9% normal saline
In which order would the nurse complete these steps when administering a blood transfusion?
1. Check primary HCP's prescription 2. Obtain vital signs and history of transfusions 3. Ascertain that IV catheter size is 18 or 20 gauge 4. Change main line solution to normal saline 5. Check client ID before hanging unit of blood
At which time would the nurse plan to administer morphine 2 mg by mouth every 2 hrs as needed to a client who has burns on 55% of the body surface and requires dressing changes?
60 minutes before the dressing change
The nurse is changing the dressing of a postoperative client. Another client has fallen near the nurses station and is unconscious. Which is the priority nursing action in this situation?
Attend to the client who lost consciousness
Which blood type is preferred for administration of blood to a client who has type B negative blood?
B negative
Which client receiving a blood transfusion who develops an adverse reaction would require immediate nursing intervention?
Wheezing
Which technique would the nurse use to maintain surgical asepsis?
Change the sterile field after sterile water is spilled on it
A client has a large, open abdominal wound. The HCP's prescription states to cleanse the wound with normal saline, pack it with damp gauze, cover with abdominal pads, and secure with Montgomery straps twice a day. Which step would the nurse take to maintain sterility when changing the dressing?
Cleanse the wound with wet, sterile gauze from the center of the wound outward
Which clinical response will the nurse assess to determine kidney damage in a client who develops a transfusion reaction?
Decreased urinary output
The nurse is caring for a client after surgical creation of an ostomy. The nurse observes that the stool is formed. The stool is this consistency in which part of the colon?
Descending
A 2 year old child is admitted with gastroenteritis and dehydration. IV fluids are prescribed. Which is the most appropriate site for the first IV insertion?
Dorsal metacarpals of hand
Which instruction would the nurse include in a teaching plan for a client who has a new colostomy and is learning how to care for the skin around the stoma?
Empty the pouch before it is 1/3 full
The spouse of a comatose client refuses to allow transfusions of whole blood because they are Jehovah's Witnesses. The client does not have a durable power of attorney for health care (DPAHC). Which action by the nurse is correct?
Give the spouse a treatment refusal form to sign and notify the primary HCP so legal action can be considered
Which action would the nurse take next after the nurse immediately stops the infusion of a client demonstrating signs and symptoms of a transfusion reaction?
Hang a bag of normal saline with new tubing
Which information would the nurse consider when planning care for the postoperative client who has a newly constructed conduit diversion (ileal conduit)
Ileal diversion conduits may provide urinary continence
A family member of a client who is prescribed a blood transfusion mentions that blood transfusions are not permitted in their faith. Which action would the nurse take to handle the situation?
Inform the primary health care provider and not give blood to the client
Which technique would the nurse use in attempting to glove the second hand when donning sterile gloves?
Insert gloved fingers under cuff of second glove and lift glove; then slide ungloved hand into glove
12 hours after sustaining full thickness burns to the chest and thighs, a client who is on NPO is reporting severe thirst. The client's urinary output has been 60 mL/h for the past 10 hours. No bowel sounds are heard. Which action would the nurse take?
Moisten the client's lips with a wet 4x4 gauze
Which intervention would the nurse implement when providing care for an older adult male client who is immobile and incontinent of urine?
Regularly offer the client a urinal. Rationale: Want to intervene in as many ways as possible before having to insert an indwelling urinary catheter
Which action would the nurse take when a client reports pain and burning at a peripheral IV site after the nurse has flushed the saline lock with normal saline?
Remove the IV catheter and restart the saline lock in another site
Which action should the nurse take to maintain sterility when performing a dressing change?
Remove the sterile drape from its package by lifting it by the corners
Which intervention is most beneficial in preventing a catheter-associated urinary tract infection in a postoperative client?
Removing the catheter within 24 hours
Which action needs correction regarding insertion of an IV cannula for administration of fluids?
Shaving the client's skin immediately around the insertion site Rationale: shaving can lead to micro abrasions, which can get infected
Which action would the nurse take first when a client who is receiving a blood transfusion develops fever, chills, and low back pain?
Stop the blood transfusion and infuse saline
Which action is the nurse's priority when the nurse notices the client receiving a blood transfusion is having an acute hemolytic reaction?
Stop the blood transfusion immediately
Which nursing action would be performed first in a client who reports chills and flank pain ten minutes after the initiation of a blood transfusion?
Stop the transfusion
The nurse is caring for a client on bed rest. Which nursing intervention would prevent a pulmonary embolism?
Teach the client how to exercise the legs
Which would the nurse include when teaching a client about the use of an incentive spirometer?
"Exhale completely; take a slow, deep breath; hold it as long as possible, and slowly exhale"
Which statement by the nursing student about the discharge instructions to be given to a postoperative client indicates that the nurse needs to intervene?
"I should instruct the client that the non-oozing wound should be cleaned with saline solution" Rationale: Non oozing wounds should be cleaned with normal soap and plain water
During a 12 hour shift, a client has a 6 oz (180 mL) cup of tea and 360 mL of water. The client vomits 100 mL, and the instilled IV fluids equaled the urinary output. Which fluid balance would the nurse record for the 12 hour period?
440 mL Rationale: 180 mL + 360 mL = 540 mL. 540 mL - 100 mL of vomit = 440 mL. IV fluids (input) equal to urinary output.
Which catheter would the nurse use when a primary health care provider has prescribed an indwelling urinary catheter for a client?
A double lumen indwelling urinary catheter
A client who had thoracic surgery reports pain at the incision site when coughing and deep breathing. Which action would the nurse take?
Instruct the client to splint the wound with a pillow when coughing
A client receiving a blood transfusion reports itching and difficulty breathing. Upon assessment the nurse notes an increase HR and low BP. Which type of shock would the nurse suspect the client is experiencing?
Anaphylactic shock
Which intervention would the nurse do before formulating a teaching plan for a child who is to undergo ostomy surgery?
Assess the child's developmental level
Which condition would the nurse suspect in a client who complains of nocturia, bladder pain, urinary frequency, urgency, any dribbling at the end of urination with a digital rectal examination report indicating smooth, firm, and enlarged prostate tissue surrounding the urethra?
Benign prostatic hyperplasia (BPH)
Which clinical finding leads the nurse to conclude that an IV has infiltrated rather than caused inflammation?
Coolness
Which action would the nurse take to prevent venous thrombus formation after abdominal surgery?
Encourage the client to ambulate multiple times daily
Which factor would the nurse recognize as the cause when a client's IV infusion infiltrates?
Failure to secure the catheter adequately
A client with a history of ulcerative colitis has a large portion of the large intestine removed, and an ileostomy is created. For which potential life-threatening complication would the nurse assess the client after this surgery?
Limited water reabsorption caused by removal of intestine
Which clinical indicator is most commonly used to determine whether the client has a fluid deficit when reporting vomiting and diarrhea for three days?
Loss of body weight
Which strategy would the nurse determine is the best method for teaching a 4 year old child about deep breathing before surgery?
Make up a game that involves using an incentive spirometer
Which possible legal complication might the nurse face in a situation in which IV therapy was administered to the wrong client?
Malpractice
Which role would the UAP have when caring for a client receiving IV therapy?
Monitoring clinical manifestations
Which nursing action is important when transfusing packed red blood cells to a client with a diagnosis of anemia?
Monitoring the client's response, particularly within the first 10 minutes
Which action by the nurse is best when a client who has a hemoglobin of 6 g/dL (60g/L) is refusing blood because of religious reasons?
Notify HCP of the client's refusal of blood products
Which evidence-based nursing intervention links to reducing CAUTIs in clients requiring long-term indwelling catheters?
Perform catheter care twice a day
The registered nurse delegates a task to a LPN. Which client task can be assigned to the LPN? a) evaluate fluid electrolyte balance b) perform sterile dressing changes on acute and chronic wounds c) notify HCP if client reports pain d) help with hearing aid placement
Perform sterile dressing changes on acute and chronic wounds Rationale: It is in the scope of practice of LPN to perform sterile dressing changes. Evaluating fluid electrolytes and notifying HCP are the RN's responsibility. Hearing aid placement can be done by UAP.
Which cause would a nurse suspect is responsible for warmth, redness, and tenderness identified at a client's IV site?
Phlebitis
Which action would the nurse take when a client refuses to take deep breaths and cough, saying "Its too painful" after an abdominal cholecystectomy?
Schedule coughing and deep breathing exercises after analgesics has taken effect
Which action would the nurse take first after observing serosanguineous drainage on the abdominal dressing of a client in the PACU who had an abdominal cholecystectomy?
Reinforce the dressing
Which action will the nurse take during administration of blood products to ensure the client's safety?
Stay with the client during first 15 min of infusion
The nurse is caring for a client 5 days after the surgical creation of a colostomy. The client has displayed signs of depression since the surgery. The nurse would determine that there is some movement toward adaptation to the change in body image when the client exhibits which behavior?
The client stares at the stoma during dressing change
Which genitourinary factor contributes to urinary incontinence in older adult clients and needs to be considered by the nurse when planning the care for these clients?
Urinary tract infection
Which problem is the nurse trying to prevent by encouraging a client with a spinal cord injury to increase oral fluid intake?
Urinary tract infection
Which finding by the nurse is the best indicator that measures to prevent postoperative atelectasis after abdominal surgery have been effective?
Vesicular breath sounds heard over both lungs