Question 1

A 55-year-old male client has a 16-Fr indwelling urethral catheter with a 5-mL balloon inserted to relieve postoperative urinary retention. The nurse observes urine leaking from the insertion site, past the catheter. What is the nurse's first action? A)Check the urethral catheter and drainage tubing B)Irrigate the catheter with 30 mL of sterile normal saline C)Notify the health care provider D)Remove and reinsert the next-larger-size catheter

Accepted Answer

11ecbb05_cb7a_6781_b433_c7e14f651011_MD0009_00 Obstruction (eg, clots, sediment), kinking/compression of catheter tubing, bladder spasms, and improper catheter size can cause leakage of urine from the insertion site of an indwelling urinary catheter. The nurse's first action should be to assess for a mechanical obstruction by inspecting the catheter tubing (Option A). These interventions may alleviate obstruction: Remove kinking or compression of the catheter or tubing.Attempt to dislodge a visible obstruction by milking the tubing. This involves squeezing and releasing the full length of the tubing, starting from a point close to the client and ending at the drainage bag. Remove kinking or compression of the catheter or tubing. Attempt to dislodge a visible obstruction by milking the tubing. This involves squeezing and releasing the full length of the tubing, starting from a point close to the client and ending at the drainage bag. If these interventions fail, the nurse should then notify the health care provider (HCP) (Option C). (Option B) Irrigation is usually avoided as pus or sediment can be washed back into the bladder; however, it is sometimes prescribed to relieve an obstruction to urine flow. If there is a discrepancy in expected urine output compared with fluid intake, a blockage is suspected and a bladder scan is then performed to confirm the presence of urine in the bladder. (Option D) The client has the recommended size of catheter and balloon for an adult male. The HCP may prescribe removal and reinsertion of a different-size catheter if other measures fail to relieve obstruction. Educational objective: If leakage of urine is observed from the insertion site of an indwelling urinary catheter, the nurse should assess for obstruction, kinking, or compression of the catheter or drainage tubing; bladder spasms; and improper catheter size.

Question 2

The nurse prepares to draw up regular and NPH insulins into one syringe. Place in order the steps the nurse should take when mixing the insulins. All options must be used. A)Clean the vial tops with alcohol swabs B)Draw up the NPH insulin solution C)Draw up the regular insulin solution D)Inject air into the NPH insulin vial E)Inject air into the regular insulin vial

Accepted Answer

11ecbb05_cb80_f73a_b433_2f55bcda70ac_MD0009_00 Mixing insulins allows multiple insulin preparations to be delivered in a single subcutaneous injection, thereby sparing the client from multiple injections. Intermediate-acting insulins (eg, NPH) can be mixed with short-acting (eg, regular) or rapid-acting (eg, aspart, lispro) insulins. Most long-acting insulins (eg, glargine, detemir) are not suitable for mixing and are typically packaged in prefilled syringes. When drawing up multiple insulins, there is a risk for contaminating the shorter-acting vials with the longer-acting insulin, which would slow the action of later doses withdrawn from the shorter-acting insulin vial. Multidose vials of regular insulin that have been contaminated with other insulins are unsafe for IV administration. When drawing up multiple insulins, the nurse should: Clean both vial tops with alcohol swabs (Option A). Inject air into the NPH insulin vial without touching the needle to the solution (Option D). Withdraw the needle from the NPH insulin vial and inject air into the regular insulin vial (Option E). Invert the regular vial and withdraw the regular solution into the syringe (Option C). Insert the needle into the NPH insulin vial and withdraw the solution (Option B). The nurse can recall the mnemonic RN (Regular before NPH). Educational objective: When drawing up multiple insulins, there is a risk for contaminating the shorter-acting insulin vial with longer-acting insulin and slowing the action of later doses withdrawn from the shorter-acting insulin vial. The nurse should withdraw the shorter-acting insulin first, and then use the same syringe to withdraw the intermediate-acting insulin.

Question 3

The nurse is preparing to suction secretions from the airway of an unconscious client whose lungs are mechanically ventilated with an endotracheal tube. Place the steps for suctioning the endotracheal tube in the correct order. All options must be used. A)Advance catheter into the trachea B)Evaluate client tolerance and document C)Gently rotate the catheter while suctioning D)Hyperoxygenate the lungs (100% FiO₂) E)Perform hand hygiene and don clean gloves F)Suction the oropharynx and perform oral care

Accepted Answer

11ecbb05_cb7c_ff95_b433_33b5ce7b97b1_MD0009_00 Clients with endotracheal tubes (ETTs) have impaired cough and gag reflexes and require suction to clear retained bronchial secretions and promote ventilatory efficacy. Ventilator circuits for ETTs typically have a reusable in-line endotracheal suction device, which remains sterile, in a flexible plastic sleeve. Oral secretions may pool near the base of the ETT and drip into the trachea; therefore, oropharyngeal suctioning and oral care are performed before ETT suctioning to prevent introduction of oral bacteria into the lungs. The steps for suctioning an ETT include: Perform hand hygiene and don clean gloves (Option E). Suction the oropharynx and perform oral care (Option F). Ensure that the system is connected to appropriate wall suction (<120 mm Hg). Hyperoxygenate the lungs (100% FiO₂) (Option D). Advance the catheter into the trachea just until resistance is met (level of the carina) (Option A). Do not suction while advancing the catheter. Gently remove the catheter while suctioning and rotating it. Do not suction for more than 10 seconds (Option C). Evaluate client tolerance; if further secretions remain, suctioning can be repeated 1 or 2 times. Document the procedure when complete (Option B). Resume oxygenation and ventilation settings as prescribed. Educational objective: Tracheal suctioning through an endotracheal tube helps clear retained bronchial secretions and increases ventilatory efficacy. The nurse must follow strict asepsis to prevent the introduction of bacteria into the lungs, hyperoxygenate the lungs to prevent hypoxia, and use appropriate technique to prevent airway trauma.

Question 4

A client arrives in the emergency department on a cold winter day. The client is calm, alert, and oriented with a respiratory rate of 20/min and a pulse oximeter reading of 78%. The nurse suspects that the client's pulse oximeter reading is inaccurate. Which factors could be contributing to this reading? Select all that apply. A)Black fingernail polish B)Cold extremities C)Elevated WBC count D)Hypotension E)Peripheral arterial disease

Accepted Answer

11ecbb05_cb82_2fbb_b433_7b50f75ed746_MD0009_00 A pulse oximeter is a noninvasive device that estimates arterial blood oxygen saturation by using a sensor attached to the client's finger, toe, earlobe, nose, or forehead. The sensor (reusable clip or disposable adhesive) contains light-emitting and light-sensing components that measure the amount of light absorbed by oxygenated hemoglobin. Because the sensor estimates the value at a peripheral site, the pulse oximeter measurement is reported as blood oxygen saturation (SpO₂). Normal SpO₂ for a healthy client is 95%-100%. Any factor that affects light transmission or peripheral blood flow can result in a false reading. Common causative factors of falsely low SpO₂ include: Dark fingernail polish or artificial acrylic nails (Option A) Hypotension and low cardiac output (eg, heart failure) (Option D) Vasoconstriction (eg, hypothermia, vasopressor medications) (Option B) Peripheral arterial disease (Option E) (Option C) Abnormal WBC count has no direct influence on light transmission or peripheral blood flow. Educational objective: Any factor that affects light transmission or peripheral blood flow can cause a falsely low reading for oxygen saturation on pulse oximeter. Common causes include dark nail polish, hypotension, low cardiac output, vasoconstriction (eg, hypothermia, vasopressor medications), and peripheral arterial disease.

Question 5

The nurse prepares to assist the health care provider with a lumbar puncture on a child with suspected meningitis. Place the procedural steps in the correct order. All options must be used. A)Assist the child into the side-lying position with the knees drawn up B)Check the medical record for parental consent C)Gather the lumbar puncture tray and supplies D)Have the child empty the bladder E)Label specimen vials as they are collected F)Place a bandage on the insertion site

Accepted Answer

11ecbb05_cb7b_2ad2_b433_477352af3a5b_MD0009_00 A lumbar puncture (spinal tap) is a sterile procedure used to gather a specimen of cerebrospinal fluid (CSF) for diagnostic purposes (eg, meningitis). A needle is inserted into the vertebral spaces between L3 and L4 or L4 and L5, and a sample of CSF is drawn. The nurse's role when assisting with a lumbar puncture includes the following: Verify informed consent Gather the lumbar puncture tray and needed supplies Explain the procedure to older child and adult Have client empty the bladder Place client in the appropriate position (eg, side-lying with knees drawn up and head flexed or sitting up and bent forward over a bedside table) Assist the client in maintaining the proper position (hold the client if necessary) Provide a distraction and reassure the client throughout the procedure Label specimen containers as they are collected Apply a bandage to the insertion site Deliver specimens to the laboratory Educational objective: When assisting with a lumbar puncture, the nurse verifies informed consent, gathers supplies, explains the procedure, has the client void, and then assists the client into position. During the procedure, the nurse provides a distraction, helps the client stay in position (if needed), and labels specimens as they are collected. Afterward, the nurse applies a bandage and ensures that the specimens are delivered to the laboratory.

Question 6

The nurse prepares to administer an IV infusion of potassium chloride through a peripheral vein to a client with hypokalemia. The health care provider's prescription states: IV potassium chloride 10 mEq (10 mmol)/100 mL 5% dextrose in water now, infuse over 30 minutes. What is the nurse's priority action? A)Assess the patency of the peripheral IV site B)Check the most current serum potassium level C)Contact the health care provider to verify the prescription D)Set the electronic IV pump to 100 mL/hr

Accepted Answer

The recommended rates for an intermittent IV infusion of potassium chloride (KCl) are no greater than 10 mEq (10 mmol) over 1 hour when infused through a peripheral line and no greater than 40 mEq/hr (40 mmol/hr) when infused through a central line (follow facility guidelines and policy). If the nurse were to administer the medication as prescribed, the rate would exceed the recommended rate of 10 mEq/hr (10 mmol/hr) (ie, 10 mEq [10 mmol] over 30 minutes = 20 mEq/hr [20 mmol/hr]). A too rapid infusion can lead to pain and irritation of the vein and postinfusion phlebitis. Contacting the health care provider to verify this prescription is the priority action. (Option A) The nurse would assess the IV site for swelling, tenderness, and redness just before initiating the KCl infusion and every 30 minutes during administration. However, this is not the priority action. (Option B) The nurse would check the most current serum potassium level just before administering the KCl and may obtain another level following the infusion, if prescribed. This is not the priority action. (Option D) An electronic IV pump should always be used to administer KCl. To administer the infusion at the recommended rate of 10 mEq/hr (10 mmol/hr), the nurse would set the pump at 100 mL/hr, but this is not the priority action. Educational objective: The maximum rate for infusion of IV potassium chloride through a peripheral vein is 10 mEq/hr, and the maximum rate through a central vein is 40 mEq/hr.

Question 7

The nurse is administering cleansing enemas to a client the night before bowel surgery.  During instillation of the enema, the client reports cramping and pain.  What action should the nurse take?
A)Have the client take slow, deep breaths
B)Stop infusing the solution for 30 seconds, then resume at a slower rate
C)Tell the client that the process will not take much longer
D)Withdraw the tube approximately 2 cm and continue the infusion

Accepted Answer

Too rapid infusion of an enema solution may cause intestinal spasms that result in a feeling of fullness, cramping, and pain. If the client reports any of these symptoms, instillation should be stopped for 30 seconds and then resumed at a slower rate. Slow infusion will also decrease the likelihood of premature ejection of the solution, which would not allow for adequate bowel evacuation. (Option A) Having the client take slow, deep breaths may be helpful, but the infusion should be stopped first. (Option C) This response disregards the client's cramping and pain and is not appropriate. (Option D) Withdrawing the tube will risk not instilling the fluid high enough into the rectum/colon to be effective. Educational objective: If a client reports cramping or pain during instillation of an enema, the infusion should be stopped for 30 seconds and then resumed at a slower rate.

Question 8

A hospitalized client is scheduled for a percutaneous kidney biopsy at 10 AM. At 8 AM, the nurse reviews the client's vital signs and most current serum laboratory results. Which finding is most important to report to the health care provider (HCP)? A)Blood pressure of 180/100 mm Hg B)Creatinine of 2 mg/dL (176.8 µmol/L) C)Hemoglobin of 9.8 g/dL (98 g/L) D)Platelet count of 120,000/mm³ (120 x 10⁹/L)

Accepted Answer

Percutaneous kidney biopsy is an invasive diagnostic procedure. It involves inserting a needle through the skin to obtain a tissue sample that is then used to determine the cause of certain kidney diseases. The kidney is a highly vascular organ; therefore, uncontrolled hypertension is a contraindication for kidney biopsy as increased renal arterial pressure places the client at risk for post-procedure bleeding. Blood pressure must be lowered and well-controlled (goal <140/90 mm Hg) using antihypertensive medications before performing a kidney biopsy (Option A). (Option B) An elevated serum creatinine level (normal: 0.6-1.3 mg/dL [53-115 µmol/L) can be expected in a client with probable renal disease. This is not the most important finding to report to the HCP. (Option C) A decreased hemoglobin level (normal adult male: 13.2-17.3 g/dL [132-173 g/L]; normal adult female: 11.7-15.5 g/dL [117-155 g/L]) can be expected in a client with probable renal disease due to decreased erythropoietin production. The nurse should continue to monitor the client's hemoglobin post-procedure as it can decrease further (within 6 hours) if bleeding occurs. (Option D) Only neurosurgery and ocular surgery require a platelet count >100,000/mm³ (100 x 10⁹/L). Most other surgeries can be performed when the platelet count is >50,000/mm³ (50 x 10⁹/L). Although the platelet count is low (normal 150,000-400,000/mm³ [150-400 x10⁹/L]), it is not the most important finding to report to the HCP. Educational objective: The kidney is a highly vascular organ and the risk of bleeding is a major complication after a percutaneous biopsy. The client should have normal coagulation studies, an adequate platelet count, and well-controlled blood pressure prior to the procedure to reduce bleeding risk.

Question 9

The nurse is preparing to administer a continuous enteral feeding for a client with a nasogastric tube. Place the steps in the correct order. All options must be used. A)Administer the prescribed feeding solution B)Elevate the head of the bed 30-45 degrees C)Flush the tube with 30 mL of water D)Identify the client using 2 identifiers E)Validate tube placement

Accepted Answer

The steps for administering a continuous enteral feeding include: Identify the client using 2 identifiers (eg, first and last name, medical record number, date of birth) (Option D) and explain the procedure to the client. Perform hand hygiene and apply clean gloves. Elevate the head of the bed ?30 degrees and keep it elevated for at least 30 minutes after feeding to minimize the risk of aspiration (Option B). Validate tube placement by checking the gastric pH as well as assessing the external tube length and comparing it with the measurement at the time of insertion. The tube should be marked at the nostril with a permanent marker during the initial x-ray validation (Option E). Check gastric residual volume. Flush the tube with 30 mL of water after checking residual volume, every 4-6 hours during feeding, and before and after medication administration (Option C). Administer the prescribed enteral feeding solution by connecting the tubing and setting the rate on the infusion pump (Option A). Educational objective: The general steps for administering a continuous enteral feeding include identifying the client, elevating the head of bed at least 30 degrees, validating tube placement, flushing the tube with 30 mL of water, and administering the prescribed enteral feeding solution.

Question 10

The nurse is feeding a confused client via a small-bore nasoenteric tube. The nurse observes the client pulling at the tube and then notices an increase in external tube length from the original exit mark. After immediately stopping the feeding, which action is appropriate for the nurse to take next? A)Advance the tube to the original exit mark, check gastric aspirate pH, and resume feeding B)Contact the health care provider to request a prescription for hand mitts C)Contact the health care provider to request an x-ray to verify tube placement D)Reinsert the guide wire and advance the tube to its original exit mark

Accepted Answer

11ecbb05_cb7d_9bd6_b433_7dca919f87d6_MD0009_00 A nasoenteric feeding tube is used for administration of continual or intermittent enteral feedings and medications. The tube is marked at the exit site (nare) with indelible ink during the initial placement x-ray. The tube may have moved out of the correct position if its external length changes. If this occurs, the nurse should contact the health care provider (HCP) and request a prescription for a repeat x-ray to determine tube location. Based on the x-ray results, enteral feeding may be resumed or the HCP may prescribe insertion of a new tube according to institution policy (Option C). (Option A) Even if bedside methods to determine placement are used (eg, gastric aspirate pH and appearance), advancing the tube to the original marking does not guarantee correct placement; these methods are not accurate indicators. Tube feedings should not be resumed after tube dislodgment without x-ray verification of correct placement. (Option B) A prescription for hand mitts to keep a confused client from disrupting enteral nutrition may be appropriate if other less restrictive interventions (eg, keeping tubing out of client's sight, one-on-one sitter) are ineffective or unavailable. However, this should not be the nurse's next action. (Option D) The guide wire (stylet) is secured before tube insertion and remains in place until placement is verified by x-ray. Once removed, the guide wire should never be reinserted while the tube is in place as it can protrude and damage both the tube and the client's mucosa. Educational objective: A feeding tube is marked with indelible ink at the exit site (nare). If the external length of the tube changes, the nurse should contact the health care provider and request a prescription for a repeat x-ray to determine tube location before resuming administration of enteral feedings and medications.

Question 11

The nurse is caring for a client with newly prescribed hearing aids. Which of the following actions by the client indicate proper use and care of hearing aids? Select all that apply. A)Keeps hearing aids clean by rinsing them with water B)Lowers television volume when talking with nurse C)Places hearing aids on food tray when not in use D)Turns volume completely down prior to insertion of aid into the ear E)Verifies that battery compartment is closed before insertion

Accepted Answer

Proper use and care of hearing aids is essential to the success of hearing aid therapy and is associated with improved outcomes. Proper hearing aid use and care include: Minimize distracting sounds (eg, television, radio) during conversation to enhance effectiveness (Option B). Turn the volume off prior to insertion, then gradually turn up the volume to a comfortable level (Option D). To adjust to the new hearing aids, initially wear them for a short time (eg, 20 minutes) and gradually increase length of wear time. Do not wear the hearing aids when using hair dryers or heat lamps. Regularly check that the battery compartment is clean, the batteries are inserted correctly, and the compartment is shut before insertion (Option E). Remove the battery (if possible) at night and when the aid is not in use to extend battery life. (Option A) Each aid must be cleaned with a soft cloth. Hearing aids should not be immersed in water, as this can damage the electrical components. (Option C) Store hearing aids in a safe, dry place when not in use. This will help prevent the hearing aids from becoming lost or damaged. Educational objective: The nurse should ensure that clients with hearing aids understand proper hearing aid use and care. Principles of hearing aid care include: turning volume off and ensuring the battery compartment is shut before insertion; minimizing background noise; cleaning the aids with a soft cloth; keeping the aids in a safe, dry place; and not immersing them in water.

Question 12

The nurse is preparing to administer several medications through a client's feeding tube. None of the medications are extended release. Which of the following actions should the nurse implement? Select all that apply. A)Combine all medications and administer together B)Crush each medication separately before administration C)Determine if the medications are available in liquid form D)Flush the tube before and after medication administration E)Mix medications with enteral feeding formula before administration

Accepted Answer

Failure to correctly administer medications through feeding tubes (eg, nasogastric, gastrostomy) can result in obstruction of the tube, reduced medication absorption or efficacy, and medication toxicity. Before administering medications through a feeding tube, the nurse should determine if any of the medications are available in a liquid form because liquid medications are less likely to clog the tube (Option C). Medications should be crushed, dissolved, and administered separately to prevent interactions (eg, chemical reactions) between medications or interference with absorption (Option B). In addition, a feeding tube should be flushed before and after each medication is given to avoid potential drug interactions and ensure tube patency (Option D). (Option A) When using a feeding tube, each medication should be administered individually to prevent interactions between medications. (Option E) Medications mixed with enteral feedings may form a thick consistency and clog the tube. Educational objective: When using a feeding tube, medications should be crushed, dissolved, and administered separately to prevent interactions. Feeding tubes should be flushed before and after each medication is given. Liquid medications should be used if possible.

Question 13

The nurse working in an intensive care unit receives a prescription from the primary health care provider to discontinue a triple-lumen subclavian central venous catheter. Which interventions will help prevent air embolism on removal? Select all that apply. A)Applying an air-occlusive dressing B)Instructing the client to bear down C)Instructing the client to lie in a supine position D)Pulling the line harder if there is resistance E)Pulling the line out when the client is inhaling

Accepted Answer

To prevent air embolism when discontinuing a central venous catheter, the nurse should perform the following interventions: Instruct the client to lie in a supine position. This will increase the central venous pressure and decrease the possibility of air getting into the vessel (Option C). Instruct the client to bear down or exhale. The client should never inhale during removal of the line; inhalation will suck more air into the blood vessel via negative suction pressure (Options B and E). Apply an air-occlusive dressing (usually gauze with a Tegaderm dressing) to help prevent a delayed air embolism. If possible, the nurse should attempt to cover the site with the occlusive dressing while pulling out the line (Option A). Pull the line cautiously and never pull harder if there is resistance. Doing so could cause the catheter to break or become dislodged in the client's vessel (Option D). Educational objective: To prevent air embolism when discontinuing a central venous catheter, it is important for the nurse to pull the line cautiously, have the client in a supine position, have the client bear down or exhale, and apply an air-occlusive dressing.

Question 14

The nurse is evaluating a return demonstration by the client of a dry dressing change. Which action by the client would cause the nurse to intervene? A)Client applies sterile adhesive dressing over gauze without touching the wound bed B)Client applies sterile gauze moistened with sterile saline to wound surface C)Client cleanses site with a sterile saline swab in a spiral pattern from the center out D)Client removes old dressing with clean gloves and checks site for signs of infection

Accepted Answer

11ecbb05_cb80_8209_b433_df326713c69c_MD0009_00 Prior to discharge, the nurse must evaluate the client's ability to perform home wound care. When performing a simple dry dressing change, the client should: Don clean gloves and perform hand hygiene before and after removing the old dressing Cleanse the wound bed using sterile saline (or a prescribed cleanser) by moving from "clean" to "dirty," or from the center of the wound outward (Option C) Thoroughly dry the wound and surrounding skin using sterile gauze to prevent maceration (breakdown) of underlying tissues Monitor the site for signs of infection (eg, redness, warmth, purulent drainage) (Option D) Apply dry, sterile gauze over the wound bed Cover the gauze with an occlusive sterile dressing to keep gauze in place and maintain asepsis. The covering should be applied without touching the wound bed (Option A) (Option B) When performing a dry dressing change, the client must make sure that the bandaging materials applied (ie, gauze) are dry. Sterile gauze moistened with sterile saline is used for wet-to-dry dressing changes and is not appropriate for a dry dressing change. Educational objective: The nurse must evaluate a client's ability to perform home wound care before discharge. Instructions for a dry dressing change should include performing hand hygiene, properly cleansing the wound bed, drying the wound, monitoring for signs of infection, and securing a dry, sterile dressing to the wound surface.

Question 15

A 7-year-old client receives a scalp laceration to the back of the head while on a playground, and the new nurse prepares to irrigate the wound. Which actions by the new nurse would require the experienced nurse to intervene? Select all that apply. A)Administers the prescribed analgesic 30 minutes before irrigating the wound B)Cleanses the wound from the most to the least contaminated area C)Obtains a 10-mL syringe and a 27-gauge needle D)Reviews the child's most recent immunization record E)Uses continuous pressure to irrigate and repeats until drainage is clear

Accepted Answer

11ecbb05_cb7e_8637_b433_d5b7910a66e6_MD0009_00 Before an open wound is closed, irrigation is performed to wash out debris and bacteria to ensure appropriate wound healing. This is important for wounds obtained in an outdoor environment (eg, playground) as contamination with soil or dirt greatly increases the risk of infection. To perform wound irrigation: Administer the analgesic 30-60 minutes before the procedure to allow medication to reach therapeutic effect (Option A). Don a gown and mask with face shield to protect from splashing fluid and sterile gloves to maintain surgical asepsis and prevent infection. Fill a 30- to 60-mL sterile irrigation syringe with the prescribed irrigation solution. Attach an 18- or 19-gauge needle or angiocatheter to the syringe and hold 1 in (2.5 cm) above the area. Use continuous pressure to flush the wound, repeating until drainage is clear (Option E). Dry the surrounding wound area to prevent skin breakdown and irritation. Immunization history is reviewed to determine tetanus vaccination status (Option D). Typically, a tetanus vaccination is administered if the client has not had one within the last 5-10 years, depending on the contamination level of the wound. (Option B) Wounds should be cleaned from the least to the most contaminated area to prevent recontamination. (Option C) A 10-mL syringe would require frequent refilling; a larger syringe is more appropriate. The narrow lumen of a 27-gauge needle would provide excessive irrigation pressure. Educational objective: Open wounds must be free of dirt and bacteria prior to closure to reduce the risk of infection. Wound irrigation requires surgical asepsis.

Question 16

The nurse is suctioning the artificial airway of a conscious client. Which actions demonstrate correct technique? Select all that apply. A)Apply suction for no longer than 5-10 seconds B)Insert catheter with low, intermittent suction applied C)Set suction higher than 130 mm Hg for thick, copious secretions D)Wait at least 1 minute between suction passes E)Withdraw catheter immediately if client begins coughing

Accepted Answer

11ecbb05_cb7c_b173_b433_a178c27391da_MD0009_00 11ecbb05_cb7c_b174_b433_37d38a97cd57_MD0009_00 The process of suctioning a client's airway removes oxygen in addition to the secretions; therefore, the client should be preoxygenated with 100% O2, and suction should be applied for no more than 10 seconds during each pass to prevent hypoxia (Option A). The nurse must wait 1-2 minutes between passes for the client to ventilate to prevent hypoxia (Option D). In addition, deep rebreathing should be encouraged. (Option B) The suction catheter should be no more than half the width of the artificial airway and inserted without suction. (Option C) The nurse should don sterile gloves if the client does not have a closed suction system in place. Suction should be set at medium pressure (100-120 mm Hg for adults, 50-75 mm Hg for children) as excess pressure will traumatize the mucosa and can cause hypoxia. (Option E) Clients usually cough as the catheter enters the trachea, and this helps loosen secretions. The catheter should be advanced until resistance is felt and then, to prevent mucosal damage, retracted 1 cm before applying suction. Educational objective: Proper airway suctioning technique includes preoxygenation, limiting a suction pass to 10 seconds, and allowing 1-2 minutes between passes to prevent hypoxia. Medium suction pressure should be set at 100-120 mm Hg for adults, with the catheter inserted without suction.

Question 17

The student nurse verbalizes the procedure for obtaining a wound culture to the nurse preceptor. Which of the following statements by the student indicate a correct understanding? Select all that apply. A)"I will apply the prescribed bacitracin ointment after collecting the wound culture." B)"I will cleanse the wound by gently flushing it with normal saline." C)"I will obtain a sample of the drainage accumulated since the last dressing change." D)"I will perform hand hygiene and apply new gloves before obtaining the wound culture." E)"I will swab the wound from the outermost margin toward the center."

Accepted Answer

11ecbb05_cb7f_2278_b433_af656ece3fa5_MD0009_00 Wound cultures identify microorganisms to aid in prescribing appropriate antibiotics and are obtained as follows: Perform hand hygiene, and apply clean gloves. Remove the old dressing. Remove and discard gloves. Perform hand hygiene, and apply sterile gloves. Assess the wound bed. Cleanse the wound bed and surrounding skin with normal saline (eg, flushing, swabbing with gauze) to remove drainage and debris (Option B). Remove and discard gloves. Perform hand hygiene, and apply clean gloves. Gently swab the wound bed with a sterile swab, from the wound center toward the outer margin (Options D and E). Avoid contact with skin at the wound edge as it can contaminate the specimen with skin flora. Place the swab in a sterile specimen container; avoid touching the swab to the outside of the container. Apply prescribed topical medication (eg, bacitracin) after obtaining cultures to prevent interference with microorganism identification (Option A). Apply new dressing. Remove and discard gloves, and perform hand hygiene. Label the specimen, and document the procedure. (Option C) Pooled purulent exudate likely contains skin flora different from the pathogen(s) responsible for the infection. Microorganisms responsible for infection are most likely found in viable tissue. Educational objective: Wound cultures are used to identify microorganisms and select appropriate antibiotics. The nurse should assess and clean the wound, swab from the wound center toward the outer margin, and avoid contamination (eg, hand hygiene, not touching intact skin with swab) to prevent misidentification of microorganisms.

Question 18

The nurse is instructing a female client how to collect a clean catch urine specimen. Place in order the steps indicating that client teaching has been effective. All options must be used. A)Cleanses vulva from front to back with single-use antiseptic towelettes B)Initiates urinary stream before passing container into stream for collection C)Performs hand hygiene and removes container lid, with sterile side placed upward D)Removes specimen container from stream before stopping urinary flow E)Spreads labia using index finger and thumb of nondominant hand

Accepted Answer

A clean catch urine specimen is commonly performed in clients requiring urinalysis. The correct collection method for a female client is as follows: Perform hand hygiene and open the specimen container, leaving the sterile side of the collection lid positioned upward to prevent contamination. Spread the labia using the index finger and the thumb of the nondominant hand so that the specimen cup can be held with the dominant hand. Cleanse the vulva in a front-to-back motion with provided antiseptic wipes, using a new towelette with each wipe to prevent contamination. Initiate the urinary stream to flush any remaining microorganisms from the urethral meatus before passing the container into the stream for the collection of 30-60 mL of urine. Remove the specimen container from the stream before the urinary flow ends and the labia are released to prevent contamination. Replace the sterile cap without contaminating it and repeat hand hygiene. Educational objective: A female client performs a clean catch urine specimen by completing hand hygiene and opening the specimen container, spreading the labia using the index finger and the thumb of the nondominant hand, and cleansing the vulva in a front-to-back motion. The client then initiates a urine stream before introducing the container midstream for urine collection. The container is removed when well filled (30-60 mL) and before urinary flow ends.

Question 19

The 70-year-old client with type 2 diabetes and hypertension is scheduled for ureteral stent removal in 2 hours. The preoperative protocol ECG is done in the inpatient unit, and results indicate a "possibly acute" ST segment elevation. What action is most important for the nurse to take? A)Document the test results on the preoperative checklist B)Notify the health care provider about the test results C)Place the printed ECG in the front of the chart D)Report the results to the surgical nurse to tell the surgeon

Accepted Answer

This is a high-risk client (eg, older age, hypertension, diabetes), and the acute, new, significant finding needs further evaluation and possible intervention before undergoing the stress of surgery. In addition, clients with a long history of diabetes often have associated neuropathy and may not experience the chest pain typical of myocardial infarction (MI), known as silent MI. As a result, the nurse must ensure that the health care provider (HCP) is made aware of this client's new findings in a timely manner. (Options A, C, and D) All of these actions should also be performed. However, the most important action is for the nurse to personally notify the client's HCP in a timely manner so that appropriate treatment can be provided. Educational objective: When significant abnormal results are obtained on a presurgical client, it is the nurse's responsibility to ensure that the health care provider is notified in a timely manner.

Question 20

The nurse prepares to administer a cleansing enema to a client with constipation. Which interventions are appropriate? Select all that apply. A)Assist the client into left lateral position with right knee flexed B)Encourage the client to retain the enema for as long as possible C)Insert tubing into the rectum with the tip directed toward the umbilicus D)Keep the enema solution refrigerated until ready to administer E)Slow administration rate if the client reports abdominal cramping

Accepted Answer

Cleansing enemas (eg, normal saline, soapsuds, tap water) relieve constipation by stimulating intestinal peristalsis. When administering an enema, appropriate interventions include: Place the client in a left lateral position with the right knee flexed (ie, Sims position) to promote flow of the enema into the colon (Option A). Hang the enema bag no more than 12 in (30 cm) above the rectum to avoid overly rapid administration. Lubricate the enema tubing tip and gently insert 3-4 in (7.6-10 cm) into the rectum. Direct the tubing tip toward the umbilicus (ie, anteriorly) during insertion to prevent intestinal perforation (Option C). Encourage the client to retain the enema for as long as possible (eg, 5-10 minutes) (Option B). Open the roller clamp on the tubing to allow the solution to flow in by gravity. If the client reports abdominal cramping, use the roller clamp to slow the rate of administration (Option E). (Option D) Enemas are administered at room temperature or warmed, as cold enema solutions cause intestinal spasms and painful cramping. Enemas may be warmed by placing the container of solution in a basin of hot water. Educational objective: When administering an enema, the nurse should place the client in the left lateral position with the right knee flexed, insert the tubing into the rectum with the tip directed toward the umbilicus, and slow the rate of administration if the client reports abdominal cramping. Enemas should be administered at room temperature or warmed.

Exam 4: Fundamentals

A 55-year-old male client has a 16-Fr indwelling urethral catheter with a 5-mL balloon inserted to relieve postoperative urinary retention. The nurse observes urine leaking from the insertion site, past the catheter. What is the nurse's first action?

The nurse prepares to draw up regular and NPH insulins into one syringe. Place in order the steps the nurse should take when mixing the insulins. All options must be used.

The nurse is preparing to suction secretions from the airway of an unconscious client whose lungs are mechanically ventilated with an endotracheal tube. Place the steps for suctioning the endotracheal tube in the correct order. All options must be used.

The nurse prepares to assist the health care provider with a lumbar puncture on a child with suspected meningitis. Place the procedural steps in the correct order. All options must be used.

The nurse is administering cleansing enemas to a client the night before bowel surgery. During instillation of the enema, the client reports cramping and pain. What action should the nurse take?

A hospitalized client is scheduled for a percutaneous kidney biopsy at 10 AM. At 8 AM, the nurse reviews the client's vital signs and most current serum laboratory results. Which finding is most important to report to the health care provider (HCP) ?

The nurse is preparing to administer a continuous enteral feeding for a client with a nasogastric tube. Place the steps in the correct order. All options must be used.

The nurse is caring for a client with newly prescribed hearing aids. Which of the following actions by the client indicate proper use and care of hearing aids? Select all that apply.

The nurse is preparing to administer several medications through a client's feeding tube. None of the medications are extended release. Which of the following actions should the nurse implement? Select all that apply.

The nurse working in an intensive care unit receives a prescription from the primary health care provider to discontinue a triple-lumen subclavian central venous catheter. Which interventions will help prevent air embolism on removal? Select all that apply.

The nurse is evaluating a return demonstration by the client of a dry dressing change. Which action by the client would cause the nurse to intervene?

A 7-year-old client receives a scalp laceration to the back of the head while on a playground, and the new nurse prepares to irrigate the wound. Which actions by the new nurse would require the experienced nurse to intervene? Select all that apply.

The nurse is suctioning the artificial airway of a conscious client. Which actions demonstrate correct technique? Select all that apply.

The student nurse verbalizes the procedure for obtaining a wound culture to the nurse preceptor. Which of the following statements by the student indicate a correct understanding? Select all that apply.

The nurse is instructing a female client how to collect a clean catch urine specimen. Place in order the steps indicating that client teaching has been effective. All options must be used.

The 70-year-old client with type 2 diabetes and hypertension is scheduled for ureteral stent removal in 2 hours. The preoperative protocol ECG is done in the inpatient unit, and results indicate a "possibly acute" ST segment elevation. What action is most important for the nurse to take?

The nurse prepares to administer a cleansing enema to a client with constipation. Which interventions are appropriate? Select all that apply.