Deck 20: Selected Nursing Skills

Question 1

When an order for eye irrigation is received,the nurse can delegate the procedure to:

A) the patient.
B) another nurse.
C) a nursing assistant.
D) a family member.

Answer 1

another nurse.

Question 2

When irrigating an ear,the nurse should perform which intervention(s)? (Select all that apply.)

A) Heat the water to 115° F.
B) Pull the auricle back firmly and hold it.
C) Place the tip of the syringe loosely in the ear canal.
D) Introduce fluid with a slow,gentle irrigation.
E) Use a stronger flow if a vegetable foreign body is present.

Answer 2

Place the tip of the syringe loosely in the ear canal.
Introduce fluid with a slow,gentle irrigation.

Question 3

When an older adult patient with chronic emphysema comes to the emergency department in respiratory distress,the nurse should begin O₂ per nasal cannula at:

A) 2 L/min.
B) 2.5 L/min.
C) 3 L/min.
D) 4 L/min.

Answer 3

2 L/min.

Question 4

During insertion of a Foley catheter,the patient grimaces as the balloon is inflated.The nurse should:

A) withdraw the catheter.
B) ask the patient to bear down.
C) continue to inflate the balloon.
D) advance the catheter into the bladder.

Question 5

While teaching a patient about the signs of IV therapy-associated phlebitis,the nurse reminds the patient that the area will be:

A) warm,edematous,and red.
B) painful and cyanotic.
C) painless and numb.
D) edematous and cool.

Question 6

After a Foley catheter has been removed,the nurse should assess the patient carefully for:

A) hemorrhage.
B) constipation.
C) urinary retention.
D) bladder spasm.

Question 7

When a patient asks if he can keep the hot application on his leg all the time,the nurse reminds him that long-term heat can:

A) cause extreme vasoconstriction.
B) increase possibility of infection.
C) cause the blood pressure to increase.
D) damage epithelial cells.

Question 8

When explaining the difference between a colostomy and an ileostomy,the nurse tells the patient that an ileostomy:

A) is always permanent.
B) drains semi-liquid stool.
C) has a much larger stoma.
D) does not need a pouch.

Question 9

When preparing to administer blood,the nurse should select a needle with a gauge of:

A) 25.
B) 22.
C) 21.
D) 18.

Question 10

When a patient receiving IV fluid therapy shows an increase in blood pressure and has bilateral crackles,the nurse's first priority is to:

A) raise the head of the bed.
B) slow the infusion.
C) turn the patient to the left side.
D) notify the charge nurse.

Question 11

The nurse explains to a patient that an Aquathermia pad differs from a traditional heating pad in that the Aquathermia pad:

A) can be folded to fit the anatomical location snugly.
B) can be placed under the patient.
C) has circulating water for temperature control.
D) can be left on for as long as 2 hours.

Question 12

When suctioning a tracheostomy,the nurse should:

A) wear clean gloves.
B) insert the catheter without suction.
C) suction for 1 minute before removing the catheter.
D) place the used catheter in a plastic shield for later use.

Question 13

The nurse notes an edematous area around the insertion site of an IV that is cool to the touch and the skin of which appears blanched.Based on these assessment findings,the nurse's first priority is to:

A) apply warm compresses to the area.
B) notify the charge nurse.
C) stop the infusion.
D) reposition the arm to improve the fluid flow.

Question 14

When a patient complains of progressive hearing loss,crackling and ringing noises in his ear,and progressive ear pain,the nurse should assess for:

A) a dead battery in the patient's hearing aid.
B) cerumen impaction.
C) sinus congestion.
D) a middle ear infection.

Question 15

The nurse instructs a patient receiving home O₂ therapy to drink plenty of fluids to help keep bronchial secretions liquefied.The recommended fluid is:

A) milk.
B) water.
C) tea with artificial sweetener.
D) coffee.

Question 16

A nurse should instill eye irrigation from the inner to the outer canthus to:

A) avoid harming the sclera.
B) include the conjunctiva in the irrigation.
C) keep the pupil constricted.
D) protect the nasolacrimal ducts.

Question 17

The nurse explains routine catheter care to the nursing assistant as:

A) cleansing the first 2 inches of the catheter with soap and water every shift.
B) disinfecting the entire catheter with alcohol every shift.
C) lubricating the catheter with antiseptic lotion every 24 hours.
D) cleansing the meatal-catheter junction every 24 hours.

Question 18

The wife of a patient with a cuffed tracheostomy asks why the cuff is inflated intermittently.The nurse replies that the purpose of the inflated cuff is to:

A) prevent regurgitation after meals.
B) hold the trachea open until it is completely healed.
C) dilate the tracheal opening for passage of secretions.
D) prevent aspiration when eating.

Question 19

Before inserting a nasogastric tube,the nurse should measure from the:

A) tip of the nose to the earlobe to the xiphoid process.
B) bridge of the nose to the xiphoid process.
C) nose to the top of the ear to the stomach.
D) clavicular notch to the stomach.

Question 20

The nurse should heat the water for an eye compress to a temperature of no more than:

A) 95° F.
B) 110° F.
C) 115° F.
D) 120° F.

Question 21

The appliance that connects to an IV drip and delivers a continuous irrigation to the eye is known as a ________ _________ _________.

Question 22

The nurse is alert for a serious condition called ___________ that results from pathogens being introduced into the blood stream.

Question 23

If a patient has a transfusion reaction,the nurse should perform the following interventions in which priori order?
1.Take and record vital signs.
2.Notify physician and blood bank.
3.Stop the transfusion.
4.Monitor urine output.
5.Return blood and tubing to the blood bank.
Put a comma between each solve choice (1,2,3,4,etc.).

Question 24

Hot moist compresses have which positive effect(s)? (Select all that apply.)

A) Improvement of circulation
B) Relief of edema
C) Consolidation of exudate
D) Enhancement of scabbing
E) Relief of pain