Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Hallmark Exam
BSN 205
| Question | Answer |
|---|---|
| Which of the following patients would require follow-up? | An adult with a respiratory rate of 10 breaths per minute |
| Which of the following vital signs recorded for an older adult would be considered acceptable (within normal limits)? | Temp 97.0 F (36.1 C), P-60, R-16, BP 116/78, O2 sat 95% |
| The nurse has delegated the task of temperature assessment to the NAP. Which information should be provided to the NAP? | The type of temperature required. The frequency for taking or monitoring the temperature. What changes to report immediately to the nurse. |
| Which of the following situations may affect a patient's vital signs? | Time of day. Pain rated as 7 on 0-10 pain scale. Moving from lying to standing position. |
| The nurse will take the patient's vital signs preoperatively and record them as part of the patient's preparation for surgery. Why is it necessary to take vital signs preoperatively? | To provide a set of vital signs to use for comparison during and after surgery. To verify the patient is not experiencing any complications that may contraindicate surgery or require intervention. |
| The NAP reports to the nurse a 65-year-old patient's blood pressure is 160/98. What is the appropriate initial response of the nurse? | Assess the patient's blood pressure |
| Which patient would it be appropriate for the nurse to delegate vital signs? | Elderly nursing home resident |
| Which person would be expected to have the lowest body temperature? | An 80-year-old who walked half a mile |
| The NAP is preparing to measure a patient's vital signs/ The patient reports having eaten a bowl of warm soup. The NAP asks the RN what he should do. What is the best response? | Ask the patient not to eat, drink, or smoke for 20 minutes and then assess the patient's oral temperature |
| For which patient would a tympanic thermometer be the preferred thermometer to use? | A tachypneic patient who is receiving oxygen by nasal canula |
| Which of the following patients would require frequent assessment of their temperature? | An adult female in the recovery room following a hysterectomy. A young adult with a white blood count of 15,000/mm^3. A patient receiving a blood transfusion for chronic anemia. |
| The NAP reports that the patient's temperature is 39 C (102.2 F). Which of the following are appropriate nursing actions? | Administer an antipyretic to the patient as ordered. Remove the patient's blankets. |
| Which of the following actions, if made by the NAP, would require intervention and further instruction by the nurse? | The NAP inserts the red-tipped electronic thermometer probe into the patient's mouth after applying a probe cover. The NAP wipes the single-use chemical dot thermometer and places it back in the patient's drawer for future use. |
| Identify the factors that may have an effect on an elderly patient's temperature. | Infection. Room temperature. Drinking a cold glass of water. Participation in physical therapy exercises. |
| If a 52-year-old patient has a normal temperature, what range should the patient's temperature fall within? | 96.8-100.4 F (36-39 C) |
| A newborn patient's temperature has been rising rapidly and the baby has been crying. Which of the following thermometers would be the best to use in measuring this patient's temperature? | Temporal artery |
| The task of pulse assessment could be delegated to the NAP for which of the following patients? | A radial pulse on a patient with a 1200 mL fluid restriction. The temporal pulse of a child. |
| Which of the following patients would be at risk for having an alteration in peripheral pulse? | The patient who was just informed of a diagnosis of cancer. A patient who is receiving bolus IV fluids. A patient with peripheral vascular disease. |
| Whenever there is an alteration in the radial pulse rate, rhythm, or amplitude, the nurse should initially do which of the following? | Auscultate the apical pulse for quality and rate |
| What is the normal pulse range for an adult? | 60 to 100 beats per minute |
| The nurse should routinely auscultate the apical pulse with the bell side of the stethoscope, and use the diaphragm side to identify heart murmurs. | FALSE |
| In which of the following patients would the nurse expect to find a decrease in pulse rate? | A patient who received morphine for pain. A patient returning from the operating room. |
| The new NAP is unable to palpate a patient's radial pulse. What could be a possible explanation for this difficulty? | The NAP is pressing down too hard on the patient's radial site. The NAP is assessing for a pulse on the ulnar side of the wrist. |
| What is an appropriate nursing intervention for an adult patient with a respiratory rate of 30 breaths per minute? | Assess physiologic factors that may be causing the patient to breathe so fast. Count the respiratory rate again for a full 60 seconds. |
| Which of the following may increase both rate and depth of respiration? | Feeling anxious when taking a test. Walking 1 mile briskly. Having an addiction problem with amphetamines/cocaine. |
| When assessing the respiratory rate, the nurse has difficulty seeing the patient's chest rise and fall with inspiration and expiration. What is the nurse's best action? | Move the patient's arm over their chest and feel the rise and fall of the chest |
| How can the nurse best obtain an accurate measurement of a patient's respiratory rate? | Continue to act as though taking the patient's pulse while discretely observing the rise and fall of the patient's chest |
| The nurse is validating the NAP's skill with respiratory rate assessment. Which of the following actions, if made by the NAP, indicates that further instruction is needed? | When a patient inhales a breath, the NAP counts that as one, and when the patient exhales the breath, the NAP counts that as two |
| The nurse assesses the BP in both arms of a newly admitted patient. Why would the nurse do this? | To determine if there is a difference in the readings between the two arms |
| Which of the following patients would be considered hypertensive after having two or more consistent readings of these values? | A football player with a diastolic BP of 94 |
| For which patient should you avoid using a leg pressure cuff to assess BP? | A patient with a deep vein thrombosis |
| The student nurse is unsure of the BP assessment. What should the student nurse do first? | Assess the BP in the other arm |
| It is 7 a.m. and the nurse takes the vital signs of a postoperative patient and finds his blood pressure is elevated. Which of the following could explain the cause for this alteration in BP? | The patient complains of pain at 9 on a 0-10 pain scale |
| The patient has history of a left mastectomy. Where should the nurse take the patient's blood pressure? | In the right arm |
| The nurse is unable to obtain a BP reading using an electronic BP machine on a post-operative patient. The machine reads "Error". What priority action should the nurse take? | Take the patient's BP manually using a sphygmomanometer |
| The NAP reports to the nurse the patient's respirations are 32 and the patient is complaining of SOB. What is the best action by the nurse at this time? | Assess the patient, including the pulse oximetry reading |
| Which patient is at high risk for the pulse oximetry alarm to sound? | A patient with a continuous pulse oximetry reading of 84% |
| A patient complains of feeling excessively tired. Which statement, if made by the NAP, indicates further instruction is needed? | "I will turn the continuous pulse oximetry alarms off at night so you can sleep" |
| The NAP tells the nurse the patient's pulse oximetry is 85% on room air. What nursing action(s) should the nurse take? | Reassess the patient's pulse oximetry. Place the patient in high-Fowler's position. Assess the patient's respiratory and cardiac status. |
| The nurse reads the following entry in a patient's health record. Based on this information, what would be the nurse's best action? Unable to obtain pulse oximetry reading. Attempted X2 fingers of each hand. Patient states has artificial nails. | Have the NAP use a different site, such as the ear lob, to obtain the SpO2 reading |
| Which of the following vital signs are expected for the adult patient who has problems in oxygenation? | Temp 98.6 F (37 C), P-102, R-28, BP98/50, O2 sat 85% |
| A healthy 30-year-old male arrives at the clinic for a physical. The nurse is responsible for collecting his vital signs. Which of these can be delegated to NAP? | Respiration. Pulse. Pulse oximetry. Temperature. BP. |
| The nurse decides to collect the patient's temperature orally using an electronic thermometer. Choose the equipment to be used. | Blue probe electronic thermometer. Thermometer cover. Patient data recording sheet and a pen. |
| The patient's BP reading is 150/80 mmHg. For this patient 80 is representative of: | The diastolic pressure. The ventricles during relaxation. |
| The nurse is having great difficulty hearing any sound when taking a patient's BP. What can the nurse do to increase the ability to auscultate the reading? | Ensure chest piece is rotated to diaphragm side. Ensure bladder of cuff is centered 1 inch above brachial artery. Reduce environmental noise by turning off TV/closing door. Keep stethoscope tubing still. Stethoscope isn't touching clothes or BP cuff. |
| The NAP reports to the nurse that the patient's pulse oximetry is 88%. What action(s) should the nurse take? | Assist the patient to a high-Fowler's position. Verify readings by taking pulse oximetry. Be prepared to administer oxygen. Perform cardiopulmonary assessment. Notify health care provider. |
| A 15-year-old male patient is hypothermic. Which temperature reflects hypothermia? | 95 F (35 C) |
| Identify why a child's respirations might be shallow. | The child is in acute pain |
| You are taking a patient's BP by using the one-step method. Which of the following is an incorrect step in the sequence for performing this procedure? | Pump the cuff to 20 mm Hg above the patient's normal diastolic pressure. Release the valve quickly. Observe the needle fall. Identify the onset of the first Korotkoff sound in mm Hg |
| A patient has been given an opioid analgesic (e.g., morphine) for pain relief. Why does the nurse assess the patient's respiratory rate before administering the next dose? | Opioid analgesics may depress rate and depth of respirations |
| A teen has come to the health care provider's office because he does not feel well after football practice. His temperature is 102°F (38.9°C). The nurse may conclude which of the following regarding this temperature reading? | This is a high temperature for a person his age |
| Who would the nurse expect to have the highest body temperature reading? | An adult female who is walking |
| Which of the following should the nurse report to the health care provider? | An adult patient with a heart rate of 55 |
| A patient was brought to the emergency department following a motor vehicle accident. He appears drowsy, but will arouse to his name being called. He is bleeding profusely from an injury to his leg. What would the nurse expect his vital signs to be? | 97.8°F (36.5°C), 110, 24, 80/40 |
| The nurse was assigned to care for five patients. Which of the following vital sign measurements would be cause for concern? | 65-year-old with blood pressure of 140/90. 75-year-old with pulse oximetry of 88% on room air. |
| The nurse reads the following nurse's note in the patient’s health record. What is the priority nursing intervention based on this information? Patient complains of headaches, almost daily, occurring more frequently in the evening. BP 164/98. P. | Obtain a complete set of vital signs and gather further assessment data |
| A nursing student is assigned to take the vital signs on a patient and finds the radial pulse to be irregular. What action should the nursing student take? | Auscultate the patient's apical pulse |
| A contaminated or traumatic wound may show signs of infection within 24 hours. A surgical wound infection usually develops postoperatively within 14 days. | FALSE |
| Healing by primary intention is expected when the edges of a clean surgical incision are sutured or stapled together, tissue loss is minimal or absent, and the wound is uncontaminated by microorganisms. | TRUE |
| Which of the following may indicate internal hemorrhage? (Select all that apply.) | Distention or swelling of the affected body part. A decreased blood pressure and increased pulse. A change in the type and amount of drainage from a surgical drain. |
| Which of the following patients has the least risk for developing a wound infection? | A 30-year-old woman who had an episiotomy with childbirth |
| When teaching a patient about wound healing, what should the nurse tell the patient? | Inadequate nutrition delays wound healing and increases risk of infection |
| The nurse is caring for a patient who had knee replacement surgery 5 days ago. The patient’s knee appears red and is very warm to the touch. Which of the following would be a correct explanation of what the nurse has assessed? | The patient is demonstrating signs of a postoperative wound infection |
| The nurse is caring for a patient after major abdominal surgery. Which of the following demonstrates correct understanding of wound dehiscence? | The nurse should be alert for an increase in serosanguineous drainage from the wound |
| The nurse reports that a patient has a wound on his abdomen that is healing by secondary intention. The nurse understands this means the patient: | Is at greater risk for infection |
| A postoperative diabetic patient had an exploratory laparotomy 5 days ago. The patient’s history indicates obesity with a body mass index of 32 and smoking 1 pack/day. Based on this information, the nurse understands the patient should be observed for: | Wound dehiscence |
| Which of the following are common sites for the development of pressure injuries? (Select all that apply.) | Heels. Sacrum. Lateral malleoli. Trochanters. Ischial tuberosities. |
| Identify contributing factors to pressure injury formation. (Select all that apply.) | Malnutrition. Decreased sensory perception/mobility. Anemia. Excessive sweating. |
| Identify prevention strategies for pressure injuries. (Select all that apply.) | When the patient is in the side-lying position in bed, use the 30-degree lateral position. Place patient on a pressure-reducing support surface. Oral supplements should be instituted if the patient is found to be undernourished. |
| The nurse is observing the patient's wife perform treatment of her husband's pressure injury. Which action, if made by the patient's wife, indicates that further instruction is needed? | She performs hand hygiene and removes the old dressing and begins to clean the injury with soap and water |
| The family member describes the pressure injury as “a blister that has now popped and you can see redness.” Based on this description, at what stage would the nurse classify this pressure injury? | Stage 2 |
| The patient asks the nurse what the purpose is for his Hemovac drain. What is the nurse's best response? | "To provide suction to remove and collect drainage from your wound to help it heal." |
| A patient is to go home with a Jackson-Pratt drain. Which of the following statements, if made by the patient, indicates further teaching is required? | "If drainage suddenly stops, it means the drain is ready to be removed." |
| When should wound drainage be cultured? | When there is a change in color, amount, or odor of drainage |
| The nurse is teaching a patient how to empty his Hemovac drain. Which action of the patient indicates that further instruction is needed? The patient: | Empties the Hemovac drain, replaces the plug, and records the amount of drainage |
| Because a patient has a Penrose drain, the nurse inspects the patient's skin and changes the dressing by placing a drainage sponge around the drain. What is the rationale for doing this? | Because drainage can be irritating to the skin and may cause skin breakdown |
| Which of the following is inappropriate to delegate to nursing assistive personnel (NAP)? | Assessment of wound drainage |
| The patient complains "It feels like the drain is pulling on my surgical site." What is the nurse’s best action? | Make sure there is slack in the tubing from the reservoir to the wound, allowing the patient movement and avoiding pulling at the insertion site |
| Which of the following are functions of dressings? (Select all that apply.) | To promote hemostasis. Wound debridement. To prevent contamination. |
| Which of the following patients would be expected to benefit from a damp-to-dry dressing? (Select all that apply.) | A 24-year-old patient with an open and infected wound from a spider bite. A 30-year-old after large cyst removal with necrotic tissue present in crater-type wound. |
| The nurse is observing the patient's wife perform the damp-to-dry dressing change. Which actions, if made by the patient's wife, indicate that further instruction is needed? (Select all that apply.) | Packs wound tightly. Leaves contact or primary dressing dripping moist. |
| A patient with a wound vacuum-assisted closure (wound V.A.C.) continues to complain of pain. What measures may be taken? (Select all that apply.) | Switch to the white polyvinyl alcohol (PVA) soft foam. Decrease the pressure setting. Administer pain medication. |
| During a sterile dressing change, when are the gloves changed? | After the old dressing is removed and before cleansing the wound |
| A patient states that she is unable to get her transparent dressing to stay in place. What instruction should the nurse provide the patient? | "Make sure that you have a margin of 1 to 1.5 inches (2.5 to 3.75 cm) around the wound, and that the skin is thoroughly dry before applying the dressing." |
| A patient asks the nurse why the Montgomery ties are being used instead of regular tape. What is the nurse's best response? | "Montgomery ties avoid frequent removal of tape, which is irritating to the skin during dressing changes." |
| How can the nurse determine that negative pressure is being achieved with a wound V.A.C.? | The nurse can check for air leaks by listening with a stethoscope or by moving the hand around the edges of the wound while applying light pressure |
| Which of the following is a correct sequence for changing a gauze dressing? | Remove old dressing, discard gloves and perform hand hygiene, create sterile field, apply sterile gloves, clean wound, blot dry, apply new dressing |
| Which of the following is an example of healing by secondary intention? (Select all that apply.) | A burn. A dog bite. A full-thickness pressure injury. |
| It is suspected that a patient is developing a wound infection. Which assessment data would support this conclusion? (Select all that apply.) | Yellow-tinged drainage. White blood cell count 13,000 mm3 (elevated). Foul odor noted from previous dressing. Temperature 100.3° F (37.94° C). Increased complaints of pain at wound site. |
| Which of the following lab results or measurements indicate a risk for impaired wound healing? (Select all that apply.) | Fasting blood glucose of 215 mg/dl (elevated). A hemoglobin of 10.0 g per dL (decreased). A serum albumin of 2.9 g/dl (decreased). A BMI (body mass index) of 35 (elevated). |
| Identify the functions of dressings. (Select all that apply.) | Maintaining a moist environment. Control of bleeding and drainage. Increased patient comfort. Protection from outside contaminants and further tissue injury. |
| Which of the following regarding removal of the old dressing on a surgical incision are accurate? (Select all that apply.) | If dressing is over a hairy area, remove tape in the direction of hair growth. Use caution to avoid tension on any drains that are present. |
| Which of the following is a method of wound debridement? | Damp-to-dry dressing |
| The nurse is teaching the nursing assistive personnel in a nursing home about daily routine measures to reduce the incidence of pressure injuries within the agency. Which of the following should the nurse include in the teaching? (Select all that apply.) | Use of pillow bridging when needed. Turning patients at least every 2 hours. Positioning patient in the 30-degree lateral position. Using a turn sheet to reposition patients. |
| How is the vacuum re-established after emptying a drain such as a Jackson-Pratt drain or Hemovac? | By compressing the drain reservoir. |
| A nurse is explaining how to perform a dressing change. Which of the following sequences for changing a surgical wound dressing (wound drain present) indicates that the nurse requires further education regarding this procedure? | Cleanse wound. Use a separate swab for each cleansing stroke. Cleanse around drain by using a circular stroke starting near the drain and moving outward. Clean incision in direction of bottom to top. |
| A patient is to have frequent dressing changes. What should the nurse use to secure the dressing? | Montgomery ties |
| Why does a wound bed need to stay moist? | To support healing by enabling granulation tissue to grow |
| A nurse is applying negative-pressure wound therapy independently for the first time. Assuming all other steps are performed correctly, which action, if made by the nurse, indicates that further instruction is needed in performing this procedure? | The nurse cuts the foam approximately one-half inch smaller than the size of the wound and gently places the foam in the wound, avoiding any tunneled and undermined areas |
| The nurse may use clean gloves for changing the dressing on which of the following? | Chronic pressure injury |
| The nurse is reading electronic documentation from the emergency room on a patient who is to be admitted to the unit. The documentation states that the patient has a hematoma on the right knee. What does the nurse expect to see? | A localized collection of blood underneath the tissues that often takes on a bluish discoloration |
| When is a surgical wound at greatest risk for hemorrhage? | During the first 24 to 48 hours after surgery |
| The nurse inspects all wounds for signs of infection. When might a contaminated or traumatic wound show signs of infection? | Two to three days after injury |
| A patient with lung cancer received radiation therapy to reduce the size of the tumor before a lobectomy. The nurse is aware the patient is at increased risk for: | Fluid and electrolyte imbalance |
| The nurse is instructing a patient on how to change a transparent dressing. Which statement, if made by the nurse, requires correction? | "You will want to remove your gloves to prevent the transparent dressing from sticking to them. Remove the paper backing of the transparent dressing and firmly stretch it over the wound to prevent wrinkling." |
| The nurse is performing a dressing change on a patient who is postoperative from a laparotomy. The patient coughs and the nurse sees a few loops of intestine uncoiling from the wound. What is the nurse’s best action at this time? | Apply sterile saline-soaked towels to the area |
| Which of the following may indicate an increased risk for wound dehiscence? | There is an increase in serosanguineous drainage from the wound |
| Which of the following patients is at greatest risk for developing a wound infection? | A diabetic obese patient who smokes |
| The nurse is caring for a patient with a Jackson-Pratt drain. Which of the following indicates correct understanding? (Select all that apply.) | The nurse ensures the drainage device appears deflated after it is emptied. The nurse instructs the NAP to measure the drainage and record on the intake & output form every 8 to 12 hours and as needed for large drainage volume. |
| A patient was diagnosed with UTI. Has been drinking fruit juice, increased fluids but failed to take antibiotics b/c it caused gastric upset. Three days later, patient presents to clinic with fever, malaise, nausea, and vomiting. What might you suspect? | The patient may now have a systemic infection |
| The nurse is preparing to insert a urinary catheter. To perform this procedure, the nurse will use: | Surgical asepsis (sterile technique) |
| The nurse sees that the patient has a gunshot wound to the chest and is concerned there may be splattering of infectious materials. The nurse applies goggles, a mask, and a gown. What is this called? | Following standard precautions |
| A nurse assists a patient with a Foley catheter to ambulate down the hall. The nurse holds the catheter bag below the level of the patient s bladder. What link in the chain of infection is the nurse breaking by doing so? | Portal of entry |
| The nurse manager is reviewing the use of standard precautions with the staff. Which of the following should be included in the review? (Select all that apply.) | Standard precautions are used to protect you from potential contact with blood and body fluids. Standard precautions should be observed in every patient encounter. |
| A small group of nursing students is giving a teaching presentation on the principles of surgical asepsis. Which of the following standards are appropriate to include in the presentation? (Select all that apply.) | Sterile barrier that has been permeated by moisture is contaminated. A sterile object or field out of the range of vision is contaminated. Any doubt about an item’s sterility, the item is considered to be unsterile. Sterile items stay in sterile field |
| A nurse is teaching infection control to a group of daycare workers. Which of the following should the nurse include in the instruction? | Immunizations help protect children from being susceptible hosts. |
| The nurse is caring for four individuals. Which patient would be most at risk for infection? | The patient who is receiving immunosuppressive medication. |
| Based on this information, what factors place this patient at risk for being a susceptible host? (Select all that apply.) | Hospitalized. Age. Vaccination status. Medical therapy. |
| The nurse is preparing an in-service on medical asepsis. Which of the following should be included in the presentation? (Select all that apply.) | If worn, fingernail polish should not be chipped. Cough hygiene practices should be followed. Always know a patient’s susceptibility to infection. |
| When should you perform hand hygiene? | Before applying gloves to insert an IV. After moving a patient up in bed. Before assessing a patient's vital signs. |
| Why are the hands rinsed with the fingertips held lower than the wrist? | Water flows from the least to the most contaminated area, rinsing microorganisms into the sink |
| What is the best nursing practice to reduce the potential transmission of microorganisms within the health care setting? | Performing hand hygiene |
| Under which circumstance(s) should hand washing be repeated? (Select all that apply.) | Hands touch the sink during hand washing. Areas under fingernails remain soiled. |
| When is it acceptable to use antiseptic hand rub rather than soap and water? (Select all that apply.) | After adjusting a nasal cannula on a patient. After removing gloves after changing a wound dressing. After moving patient’s belongings on the bedside table. |
| The nurse is observing the NAP perform hand hygiene. Which of the following, if performed by the NAP, requires intervention by the nurse? (Select all that apply.) The NAP: | Takes the patient’s blood pressure and leaves the room to document. Puts the patient's socks on, then begins to feed the patient. Has an uncovered cut on the back of the nondominant hand. |
| The NAP complains of his hands hurting and skin being chapped. What would be appropriate suggestions for the NAP? (Select all that apply.) | Use hand lotion from an individual use container. Be sure to rinse and dry hands thoroughly. Avoid excessive amounts of soap or antiseptic. |
| The nurse is preparing a sterile field. Which of the following would be considered contamination of the field? (Select all that apply.) | Some of the sterile normal saline spills onto the sterile barrier. Nonsterile items are added to the sterile field. The nurse prepares the sterile field and leaves the room to get more sterile supplies. |
| The nurse is reviewing with the surgical technician how to prepare a sterile field. Which of the following is incorrect and should not be included in the review? | Place the drape so the top half of the drape is over the top half of the work surface |
| The nurse is preparing to set up a sterile field for a patient who is going to have a sterile dressing change. Which of the following assessment measures would be unnecessary at this time? | The nurse asks the patient if he has ambulated in the hall today |
| One evaluation measure of creating and maintaining a sterile field involves monitoring the patient for developing signs and symptoms of localized or systemic infection. Which of the following is cause for concern? | Temperature of 102.5° F (39.2° C) |
| A nurse is preparing a medication for subcutaneous administration. As the nurse recaps the needle using the scoop method, the nurse accidentally touches the table with the uncovered needle. What is the nurse’s best action? | Discard the needle and replace with a new one before administration |
| The nurse is adding a dry sterile gauze dressing to the sterile field. The dressing bounces on the surface and lands on the outer 1-inch border of the sterile field. What action is appropriate at this time? | The nurse opens another sterile gauze dressing and adds it to the sterile field, but does not use the first one |
| The nurse is applying sterile gloves. Which series of steps would require correction? | Hold gloved hands at sides of body, below waist level, until beginning the sterile procedure |
| The nursing instructor is asking the nursing students to share their knowledge regarding sterile gloving. Which statement, if made by a student, would require correction? | Once sterile gloves are applied, the inside of the glove is still considered sterile |
| Which of the following are symptoms of latex allergy? (Select all that apply.) | Skin redness. Itching. Edema. Difficulty breathing. |
| Which factors would be considered high-risk factors for latex allergy? (Select all that apply.) | History of multiple surgeries as a child. Occupation. |
| Which of the following are symptoms of a systemic infection? (Select all that apply.) | Nausea and vomiting. Fever. Fatigue. |
| Which of the following patients are at risk for developing an infection? (Select all that apply.) | A patient with an IV. A patient with a chronic respiratory disease receiving steroid therapy. A patient receiving chemotherapy. |
| The patient reports an allergy to latex. What alterations should be made in the patient's care? (Select all that apply.) | Remove items that contain latex in the care of the patient. Determine whether syringes, IV tubing, and catheters contain latex. Use latex-free or synthetic gloves when gloves are necessary. |
| The nurse is observing the NAP perform hand washing. During which step should the nurse intervene and provide further instruction? | The NAP wets his hands and wrists thoroughly under the running water and keeps his hands and forearms higher than the elbows during washing |
| A new quality assurance program has been instituted on the unit because of a higher than average infection rate. Which of the following could be factors responsible for this increase? (Select all that apply.) | Nurse F has chipped nail polish. Nurse E has open cuts on her hand. Nurse A wears artificial nails. |
| A NAP asks what an example would be of using standard precautions. The nurse is correct to respond: | Wearing clean gloves when emptying a bedpan |
| A nurse is obtaining a patient’s medical history when he states, “I am HIV positive because I shared needles with a friend who is also HIV positive.” The friend would be considered: | The reservoir |
| A nursing instructor is reviewing medical asepsis with a group of nursing students. Which comment, if made by a student, indicates that further teaching is needed? | "Alcohol-based hand rubs should be used often when caring for patients with Clostridium difficile." |
| The nurse is performing hand hygiene. Which would be an inappropriate action? (Select all that apply.) | Drying hands from wrists to fingers with a paper towel. Using hot water to rinse the hands after lathering. Using friction for 10 seconds in a vertical motion. |
| You are reviewing the signs, symptoms, and prevention of hypoxia with the family of a patient who requires frequent suctioning at home. Choose the information that you should cover. (Select all that apply.) | Restlessness and anxiety. Confusion, disorientation, and altered consciousness. Increases in pulse, respiration, and blood pressure. Having difficulty breathing and looking blue. ALL ARE INDICATIONS OF HYPOXIA. |
| Which of the following are risk factors for this patient developing hypoxia? (Select all that apply.) | Anemia. Increased secretions with weak cough. Impaired cardiac function. Pneumonia. |
| Which of the following patients would have the greatest potential for an alteration in respiration? | A 44-year-old woman with anemia |
| Which of the following, if exhibited by the patient, is a late sign of hypoxia? | Cyanosis |
| Which of the following would lead to an increase in oxygen demand? | A fever |
| What nursing intervention is appropriate for the patient with a large amount of sputum? | Encourage the patient to cough every hour while awake |
| Which assessment parameters indicate the need for oral suction? (Select all that apply.) | Unusual restlessness. Gagging. Gurgling and adventitious lung sounds. Evidence of emesis in the mouth. Persistent coughing that fails to clear airway. Weakness and lethargy accompanied by drooling. |
| The nurse is performing routine assessments of the patients on the unit. The nurse notes audible gurgling on inspiration and expiration of the stable postoperative patient. Which of the following tasks can be delegated to competent NAP? | Performing oral suctioning |
| The nurse is preparing to perform oropharyngeal suctioning. Which of the following steps in the sequence is incorrect? | Assist the patient into a supine position. Prepare supplies. Turn the suction unit on and set the suction control gauge to high. Connect the suction tubing to the suction machine and to the Yankauer suction catheter. |
| The nurse is teaching the spouse of a patient how to perform oral suctioning for when they return home. Which of the following statements, if made by the spouse, indicates further instruction is needed? | “Because oral secretions are thick, suction settings should always be set on high.” |
| Which of the following patients is most likely to experience some difficulty with effective coughing? | The patient who is postoperative for abdominal surgery |
| Which of the following patients should be assessed for a worsening clinical situation? | The patient with presence of blood in the secretions |
| Which of the following patients may likely require oropharyngeal suctioning? (Select all that apply.) | A patient who had maxillofacial surgery. A patient who had trauma to the mouth. A patient with impaired swallowing from neurological injury. A patient with an artificial airway who requires oral hygiene. |
| Which of the following should NOT be delegated to nursing assistive personnel (NAP)? | Nasotracheal suctioning |
| The nurse desires to suction the patient’s left main-stem bronchus. In what position should the patient be placed? | Turn the patient’s head to the right |
| The nurse is orienting a new graduate nurse to common procedures performed on the unit. Which statement, if made by the graduate nurse, indicates understanding of nasotracheal suctioning? | "A 1- to 2- minute interval should be allowed between suctioning passes." |
| A discussion is taking place on the unit regarding the application of lubricant to the suction catheter before passing it through the nasal passage. Which statement is accurate? | “Water-soluble lubricant should be used because oil based lubricants increase the risk for aspiration and pneumonia.” |
| The nurse performs nasotracheal suctioning. Which of the following is an incorrect sequence for this procedure? | Apply sterile gloves, pick up the suction catheter with dominant hand, secure the catheter to the tubing, connect the tubing to the suction machine, and turn the suction on. |
| Which of the following is a potential complication for a patient who is having nasotracheal suctioning? (Select all that apply.) | A significant drop in oxygen concentration. A decrease in heart rate. Dysrhythmias. |
| For a patient with an endotracheal tube on mechanical ventilation, preoxygenation is unnecessary before suctioning because the ventilator will maintain the patient's oxygen levels. | FALSE |
| Which of the following statements regarding nasotracheal suctioning are true? (Select all that apply.) | Sterile technique is required. Suction should be applied intermittently as the catheter is removed. The suction catheter should be rotated as it is withdrawn. |
| The nurse is preparing to perform nasotracheal suctioning on a patient. Which of the following actions would indicate a break in sterile technique? (Select all that apply.) | As the nurse places the sterile basin on the bedside table, the nurse touches the inside of the basin with the nonsterile glove. The nurse uses the same suction catheter to suction the oral cavity followed by the endotracheal tube... |
| Before performing endotracheal suctioning, the nurse presses the sigh mechanism on the mechanical ventilator. Why does the nurse do this? The nurse is: (Select all that apply.) | Preoxygenating the patient. Offsetting the volume of oxygen lost during the suction procedure. Compensating for the interruption in mechanical ventilation. |
| Which of the following demonstrate that further teaching is required to prevent an infection related to being catheterized? (Select all that apply.) | An elderly female patient carries her urinary drainage bag like a purse as she ambulates. As a patient is being transferred in a wheelchair, he places the drainage bag in his lap. The NAP places a patient’s drainage bag on a lowered side rail... |
| Which of the following are true regarding the impact of aging related to urinary elimination? (Select all that apply.) | Aging can affect continence if the patient experiences impaired mobility or decreased muscle tone. The elderly are at increased risk for urinary tract infection because of retained urine in the bladder. |
| During change-of-shift report the nurse states that a patient has early renal failure and to be alert to this when administering medications. Why would this be a concern? | The kidneys assist in the detoxification of medication metabolites |
| The nursing instructor is reviewing the renal system and urinary catheterization with her students. Which statement, if made by a nursing student, indicates that further instruction is needed? | "The nurse may use clean technique to insert an indwelling catheter." |
| A 53-year-old patient is being treated for hypertension and a history of thrombophlebitis. She comes to the clinic complaining, "I have to get up all night to go to the bathroom, and I think my urine looks orange!" What is the nurse’s best response? | "What medications are you taking and when?" |
| A 68-year-old female patient is admitted for knee replacement, an expected hospital stay of 2 weeks. She has no known allergies. The health care provider has ordered an indwelling catheter. Which catheter should the nurse choose? | 14 French, 5-mL balloon, latex catheter |
| A health care provider has ordered an indwelling catheter to be inserted for bedside drainage. Which of the following is NOT an expected indication for catheterization with an indwelling catheter? | To determine urinary retention |
| A nurse is explaining the procedure for inserting an indwelling urinary catheter. Which of the following explanations regarding anchoring of the catheter would be most accurate? | It is important to anchor the catheter tubing to minimize the risk for urethral trauma and bladder spasms from traction and to prevent accidental dislodgment |
| A nurse inserting an indwelling urinary catheter in a female patient advances the catheter and obtains clear yellow urine. What is the next action the nurse should take? | Advance catheter another 1 to 2 inches and inflate balloon |
| The nurse has inserted a catheter 7.5 cm (3 inches) in a female patient and obtains no urine return even though her bladder is distended. What action should the nurse take at this time? | Leave the catheter in the vagina as a landmark and insert another sterile catheter |
| The nurse has a sterile urinary catheter and sterile gloves. Choose the remaining equipment the nurse will need to insert a straight urethral catheter: (Select all that apply.) | Sterile cotton balls. Antiseptic solution. Water-soluble lubricant. Sterile forceps. |
| Reasons for lack of urine after inserting a straight catheter include: (Select all that apply.) | The catheter is outside of the bladder. The catheter is inserted in the vagina rather than in the urethra of a female patient. |
| A nursing student is watching a nurse catheterize a female patient with an indwelling catheter. Which of the following, if it occurs, indicates a break in sterile technique? (Select all that apply.) | Nurse inserts urinary catheter, when urine does not return, makes a second attempt with same catheter. Nurse lubricates catheter and places it back into sterile tray when it uncoils and touches bed. After nurse cleans labia, it become slippery and closed. |
| Which of the following actions associated with urinary catheterization could cause a potential problem? | Keeping the foreskin retracted after catheterization |
| A 40-year-old male patient has been admitted for abdominal surgery. He has no history of prostate problems. Health care provider has ordered that the patient be catheterized. Which of the following would be an appropriate-size catheter for this patient? | 16 French, 5-mL balloon |
| As part of catheter insertion assessment, where should the nurse palpate? | Above the symphysis pubis |
| Nurse is inserting an indwelling Foley catheter in male patient. Nurse asks patient to bear down as if to void and slowly inserts catheter through urethral meatus. Nurse advances catheter and meets resistance. What is nurse’s best initial action? | Ask the patient to take slow deep breaths while inserting the catheter slowly |
| The nurse is catheterizing a female patient and obtains a clear amber urine return. As the nurse begins to inflate the balloon, the patient complains of pain and resistance is felt. What is the nurse’s best action? | Allow fluid to flow back into syringe and advance the catheter a little more before attempting to reinflate |
| The nurse is reviewing urinary catheter care with a newly hired nursing assistive personnel (NAP). Which statement made by the NAP indicates further instruction is needed? | “The bedside drainage bag should only be emptied when it is full.” |
| The NAP documents “Peri-care given” next to “Urinary Catheter” on a patient with an indwelling urinary catheter. What is the best explanation of what the NAP did after application of clean gloves? The NAP: | Stabilized the catheter and washed the catheter with soap and water from where the catheter enters the meatus down 4 inches toward the drainage tubing |
| Which of the following indicates a reason for notifying the health care provider to get an order for removal of an indwelling catheter? | The patient’s urine appears cloudy with a foul odor |
| Identify the indicators of a UTI: (Select all that apply.) | Fever. Complaints of pain with urination (dysuria). Lower abdominal pain. Cloudiness of the urine. |
| Which of the following steps should you take before removing fluid from the balloon in an indwelling urinary catheter? (Select all that apply.) | Attach a 10 mL or larger syringe to the balloon port and allow the water to passively fill the syringe. Gently aspirate the syringe plunger if water remains in the balloon. |
| A patient had an indwelling catheter for 3 weeks. Patient had the catheter removed 3 hours ago and now complains of having to go to the bathroom frequently and that it is painful to void. Which instruction is appropriate for the nurse to give the patient? | "This is a normal occurrence after having a catheter in place for more than several days." |
| If a patient's indwelling catheter is removed at 0900, the patient should be due to void by: | 1500 to 1700 (3:00 PM to 5:00 PM) |
| Which of the following is the best example of documentation on a patient with a urinary catheter? | Catheter care provided; no encrustation noted. Urinary catheter patent and draining clear yellow urine to bedside drainage bag |
| The nurse is reviewing how to perform a bladder scan for determining postvoid residual (PVR) with nursing assistive personnel (NAP). Which of the following statements, if made by the NAP, indicates understanding? (Select all that apply.) | "I will measure and record the patient’s intake and output." "I will apply ultrasound gel above the patient’s symphysis pubis." "I should point the scanner head downward toward the bladder." |
| The nurse works on a surgical unit. For which of the following patients would a nurse expect to perform a bladder scan? (Select all that apply.) | A patient who had an indwelling urinary catheter removed 8 hours ago and voided 30 mL once since it was removed. A patient who complains she is having urinary incontinence and never had this problem before. A patient who is posto for urological surgery. |
| The nurse wipes the abdomen of the gel and documents the procedure. What error(s) occurred in the performance of the skill? (Select all that apply.) | The length of time between the patient voiding and performing the bladder scan. The timing of pressing and releasing the scan button. Cleaning of the scanner head. |
| Four patients had a bladder scan for PVR. For which of the following patients would further investigation be required? | A patient with PVR measurements of 125 mL and 150 mL |
| The nurse is to determine PVR on a patient who has been experiencing incontinence, but a bladder scanner is unavailable. What is the nurse’s best action? | Have the patient void and measure the volume, then perform straight catheterization |
| The patient is to have intermittent irrigation of a double-lumen urinary catheter. The patient asks why the nurse is kinking the drainage tubing and putting a rubber band on it. What is the nurse’s best response? | "This prevents the irrigating solution from going down into your drainage bag rather than into your bladder." |
| NAP reports patient who is 1 day postoperative from bladder surgery is complaining of lower abdominal pain. Nurse palpates patient’s bladder and finds it distended and there has not been any change in amount urine. What is the nurse’s best action? | Ensure there are no kinks in drainage tubing, and if none, notify health care provider for possible bladder irrigation order |
| A patient returned from urological surgery with closed continuous bladder irrigation. The patient’s wife voices concern regarding the “bloody-red” appearance of the drainage. What is the nurse’s best response? | "This is normal at this time; the drainage will become lighter and appear blood tinged in 2 to 3 days." |
| The nurse is preparing continuous bladder irrigation. Which of the following actions by the nurse would be appropriate? (Select all that apply.) | Performing hand hygiene and donning clean gloves. Priming the infusion tubing with irrigating solution. Calculating urinary output as amount of irrigant infused subtracted from drainage. Monitor and empty drainage bag as needed. |
| Nurse is performing preop teaching for patient who is having urological surgery. Nurse informs patient he will likely require closed bladder irrigation. Patient asks what the purpose is. What would be a correct response by the nurse? | "Bladder irrigation may be used to instill medication into the bladder." "Irrigating the bladder prevents any clots or sediment from blocking urinary drainage." |
| The nurse is teaching the male patient and family caregiver about the advantages of a condom catheter. Which of the following should be included in the teaching? (Select all that apply.) | It is relatively safe and noninvasive. It's a convenient method of draining urine. It's used for male patients who are incontinent. It carries less risk of developing a UTI than an indwelling catheter. |
| Which of the following would be inappropriate to delegate to NAP? | Indwelling catheter insertion |
| Which of the following could be considered negligence? | A regular condom catheter is removed every 3 days |
| During application of the condom catheter, the adhesive strip falls to the floor. What is the nurse’s best action? | Obtain another adhesive strip from condom catheter kit |
| The nurse is assessing the patient’s condom catheter. Which of the following most likely indicates the condom catheter should be removed? | Redness and/or excoriation of the penis |
| The NAP is applying a condom catheter to the patient. The patient asks, “What is the purpose of the skin preparation solution?” The NAP correctly responds: | “The skin preparation solution prevents skin irritation and should be dry before the condom catheter is applied.” |
| If a patient had to have part of the colon (large intestine) removed, which of the following may result? | The patient could experience an acid-base imbalance |
| A nurse is admitting a patient to the unit. The nurse is aware that the patient is at increased risk for constipation if the following are present in the patient's health history or admission assessment: (Select all that apply.) | The patient is an elderly woman. The patient takes opioids for chronic back pain. The patient takes daily iron and calcium supplements. |
| A student nurse is studying the GI system in preparation for an exam. Which statement indicates correct understanding? | The ascending colon would be found in the right side of the patient s abdomen |
| An increase in venous pressure caused by liver disease can result in the development of: | Hemorrhoids |
| The comatose patient in the intensive care unit (ICU), who has not had a bowel movement in 4 days, suddenly is incontinent of liquid stool. What should the nurse suspect? | Impaction |
| The nurse is monitoring the patient for a possible vagal response while removing a fecal impaction. If the patient had a vagal response, what would the nurse most likely observe? | A decrease in heart rate |
| An adult patient is scheduled for an abdominal computed tomography (CT) scan. Before the scan he must receive a cleansing tap water enema. The nurse should prepare: | 1000 mL or less of tap water |
| The health care provider has ordered a Fleet enema for a patient experiencing constipation. Which of the following actions would require correction? | The nurse squeezes and releases the bottle several times until all of the solution has entered the patient |
| An adult patient complains of cramping during the administration of an enema. What could be a possible cause? (Select all that apply.) | The solution was instilled too rapidly. The enema solution was too cold. |
| Which of the following is the best example of documentation of enema administration? | 0830 800 mL tap water enema administered. Return clear with no fecal material Bowel sounds present in all 4 quadrants pre and post procedure. Abdomen nondistended. Patient states "I’m glad that’s over." |
| The nurse is observing the NAP administer a soap suds enema to an adult patient. Which of the following actions, if made by the NAP, would require correction? | The NAP inserts the tip of the rectal tube 5 to 7 inches after lubricating it |
| A patient is to receive enemas "until clear." The nurse notes that stool remains in the fecal return after the second enema. What should the nurse do? | Administer a third enema |
| An infant is to have an enema. Which solution would the nurse anticipate using? | Normal saline |
| A patient has a loop colostomy. The patient complains that the distal stoma looks like it is secreting mucus. What is your best response? | "The distal stoma may secrete mucus and that would be normal." |
| A patient has been admitted for surgery for a colostomy. The patient states, "I can’t believe this has happened to me." What is the nurse’s best response? | "It will be a change for you, but a normal lifestyle is still possible. What concerns you the most?" |
| A patient is scheduled to have an ileostomy. The patient asks, "Will I always have to wear a pouch?" What is the nurse’s best response? | "Unless an internal pouch is surgically created, the effluent of an ileostomy is very liquid and must be pouched at all times." |
| The nurse is pouching an enterostomy. Assuming all other steps are performed correctly, which of the following steps is incorrect? | The nurse cleans the peristomal skin vigorously with warm tap water, selects a pouch, removes the backing and cuts the opening on the pouch to one-quarter inch larger than the stoma |
| When is the best time to change the skin barrier pouch? (Select all that apply.) | Several hours after breakfast. Several hours after lunch. |
| Identify the equipment needed to pouch an enterostomy by using a precut system. (Select all that apply.) | Basin with warm tap water. Gauze pads or washcloth. Towel or disposable waterproof barrier. Pouch closure device such as a clamp. Clean disposable gloves. Pouch: clear drainable colostomy/ileostomy in correct size for two-piece system or a one-piece type |
| Identify interventions for irritation around the stoma. (Select all that apply.) | Make sure there is a good seal of skin so that undermining of fecal contents will be avoided. Determine whether patient’s skin is reacting to adhesive. Consult ostomy care nurse. Determine whether a different type of pouching system is needed. |
| Nursing assistive personnel (NAP) reports the patient's stoma appears purple. What would likely be the cause? | A lack of circulation to the stoma |
| The nurse is teaching the patient how to pouch an ostomy. Which statement, if made by the patient, indicates further instruction is needed? | “I should clean the peristomal skin with soap and warm water.” |
| From the following, choose the four primary functions of the colon. (Select all that apply.) | Elimination. Secretion. Protection. Absorption. |
| From the following, choose the correct equipment to bring to the bedside to administer the commercially prepared Fleet enema. (Select all that apply.) | Waterproof bed pad. Water-soluble lubricant. Commercially prepared enema product. Clean disposable gloves. Toilet paper and/or basin with warm water, washcloth, and towel. |
| The nurse listens for bowel sounds before administering an enema. The patient asks, “Why are you listening to my abdomen?” The nurse's accurate response is: | “To determine the presence of bowel sounds, which indicates the intestines are working.” |
| To which of the following patients would it be considered acceptable to administer an enema without the nurse needing to question the order? | A patient who is going to have abdominal surgery |
| A nurse is preparing to administer an enema. Which of the following actions indicates correct understanding? | The nurse holds the tubing in the patient's rectum constantly until the end of fluid instillation |
| The nurse is reviewing enema administration with nursing assistive personnel (NAP). Which of the following statements by the NAP indicates further instruction is necessary? | “The rectal tube of an enema should be inserted 5 to 7.5 cm (2 to 3 inches) into the rectum of an adolescent.” |
| Which of the following would be considered a normal finding after the administration and evacuation of an enema? | Abdominal distention is absent |
| The patient is complaining of cramping during instillation of the enema solution. What is the most appropriate action by the nurse? | Lower the height of the enema container or clamp the tubing |
| Which of the following is considered a sterile procedure and therefore requires sterile gloves? | None of the above |
| The nurse understands the important role in helping the patient with an ostomy accept their change in self-image. Which of the following indicates the patient is having difficulty with this change in body image? | The patient continues to rely on the nurse to change the ostomy pouch |
| How often should an ostomy pouch be changed? | Every 3 to 7 days |
| The nurse is pouching a new ostomy. The patient asks why the nurse always measures the size of the stoma. Which of the following would be an inaccurate response by the nurse and would require correction? | “The stoma typically increases in size with the passage of time.” |
| Which of the following would be inappropriate to delegate to NAP? | Pouching a newly established ostomy |
| The NAP tells the nurse she doesn't want to care for a certain patient because she is afraid of contracting C. difficile. Which is the best response by the nurse? | “Good hand hygiene with soap and water is your best defense against C. difficile.” |
| The nurse instructs the patient that the health care provider has ordered an enema. The patient states, An enema! I m not constipated. What are other possible reasons for the order? (Select all that apply.) | Preparation for a diagnostic procedure. To administer a medication. Preparation for surgery. |
Created by:
MzSimmons