Urinary Catheter Care and Wound Healing: Best Practices and Indications, Exams of Nursing

Download Urinary Catheter Care and Wound Healing: Best Practices and Indications and more Exams Nursing in PDF only on Docsity! 1 BSN 205 Hallmark Final Exam Questions and Answers 2024 Which of the following is an example of healing by secondary intention? A. A Full thickness pressure injury B. A surgical incision C. A dog bite D. A burn E. A skin tear - CORRECT ANSWER A Full thickness pressure injury A dog bite A burn To allow a pressure ulcer on the coccyx to heal in a patient with urinary incontinence. - CORRECT ANSWER 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? An indwelling catheter tube is secured to a female patient's abdomen to prevent accidental dislodgment. An indwelling catheter tube is secured to the male patient's inner thigh with a strip of nonallergenic tape or a commercial tube holder. 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. 2 When securing the catheter tubing, slack in the catheter should be avoided to prevent movement and possible tissue injury. - CORRECT ANSWER 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? Inflate the balloon with the prefilled syringe of sterile water in the balloon port. Pull gently back on the catheter approximately 1 inch or until resistance is met. Advance catheter another 1 to 2 inches and inflate balloon. Ask patient to bear down as if to void. - CORRECT ANSWER 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? Remove the catheter and have another nurse attempt to catheterize the patient. Leave the catheter in the vagina as a landmark and insert another sterile catheter. Remove the catheter and reinsert into the urethra. The nurse may straighten the urethra by inserting one finger of a sterile-gloved hand inside the vagina and applying gentle pressure upward. 5 The nurse lubricates the catheter and places it back into the sterile tray when it uncoils and touches the bed. After the nurse cleans the labia, the labia become slippery and closed as the nurse attempts to obtain a clear view of the urethra. Which of the following actions associated with urinary catheterization could cause a potential problem? Attaching the bedside drainage bag to the bed frame. Keeping the foreskin retracted after catheterization. Failing to test the balloon by injecting fluid from prefilled sterile water syringe into the balloon port before insertion. Cleansing the far labial fold, the near labial fold, and directly over the center of urethral meatus using a new swab with each area. - CORRECT ANSWER 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. The health care provider has ordered that the patient be catheterized. Which of the following would be an appropriate-size catheter for this patient? 8 French, 3-mL balloon 12 French, 5-mL balloon 16 French, 5-mL balloon 16 French, 30-mL balloon - CORRECT ANSWER 16 French, 5- mL balloon 6 As part of catheter insertion assessment, where should the nurse palpate? At the costovertebral angle. Above the symphysis pubis. Starting at the right iliac crest and moving upward along the midclavicular line. Midway between the xyphoid process and symphysis pubis. - CORRECT ANSWER Above the symphysis pubis. The nurse is inserting an indwelling Foley catheter in a male patient. The nurse asks the patient to bear down as if to void and slowly inserts the catheter through the urethral meatus. The nurse advances the catheter and meets resistance. What is the nurse's best initial action at this time? Ask the patient to take slow deep breaths while inserting the catheter slowly. Withdraw the catheter and notify the health care provider. Apply more force to insert the catheter inward. Remove the catheter, apply more lubricant, and reinsert. - CORRECT ANSWER 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? 7 Allow fluid to flow back into syringe and advance the catheter a little more before attempting to reinflate. Have the patient take slow deep breaths, inhaling through the nose and exhaling through the mouth. Lift penis to position perpendicular to patient's body, and apply light traction. Advance catheter to bifurcation of the drainage tube and balloon inflation port. - CORRECT ANSWER 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? "Urinary catheter care is a clean procedure; sterile gloves are unnecessary." "The bedside drainage bag should only be emptied when it is full." "The securement device that anchors the catheter should be reapplied." "Catheter care can be delegated to nursing assistive personnel." - CORRECT ANSWER "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: 10 syringe to the balloon port and allow the water to passively fill the syringe. A patient had an indwelling catheter for 3 weeks. The 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." "It sounds like you have a UTI. I will notify your health care provider." "I will need to inspect your perineal area and wash and dry the area." "If these symptoms continue, I will notify your health care provider to see if we can reinsert the catheter." - CORRECT ANSWER "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: 1900 to 2100 (7:00 PM to 9:00 PM) 1100 to 1200 (11:00 AM to 12:00 PM) 1500 to 1700 (3:00 PM to 5:00 PM) 0930 (9:30 AM) - CORRECT ANSWER 1500 to 1700 (3:00 PM to 5:00 PM) 11 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. Catheter care provided. 14 French catheter intact with approximately 30 mL urine in bedside drainage bag. Unable to palpate urinary bladder. Patent denies discomfort; indwelling catheter draining well. Patient instructed on signs and symptoms of UTI and how to prevent while catheterized. - CORRECT ANSWER 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.) "This test requires the patient to follow fluid intake restrictions." "I will measure and record the patient's intake and output." "I will perform the bladder scan and then have the patient urinate." "I will apply ultrasound gel above the patient's symphysis pubis." "I should point the scanner head downward toward the bladder." - CORRECT ANSWER "I will measure and record the patient's intake and output." "I will apply ultrasound gel above the patient's symphysis pubis." 12 "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 postoperative for urological surgery. A patient who was placed on diuretic therapy to reduce peripheral edema. A patient who reports a change in urine color. - CORRECT ANSWER 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 postoperative for urological surgery. A nurse is to perform a bladder scan on a patient to measure PVR. After the patient voids, the nurse measures and documents the volume of voided urine. The nurse returns in 20 minutes and places the patient supine with head slightly elevated, exposing the patient's lower abdomen. The nurse turns on the scanner and sets the gender designation. The nurse applies a generous amount of ultrasound gel above the patient's symphysis pubis, 15 A hemoglobin of 10.0 g per dL (decreased) A serum albumin of 2.9 g/dl (decreased) Fasting blood glucose of 215 mg/dl (elevated) A BMI (body mass index) of 35 (elevated) A white blood cell count of 7000 per mm3 (normal) - CORRECT ANSWER A hemoglobin of 10.0 g per dL (decreased) A serum albumin of 2.9 g/dl (decreased) Fasting blood glucose of 215 mg/dl (elevated) A BMI (body mass index) of 35 (elevated) Identify the functions of dressings. (Select all that apply.) Removing surface bacteria. Preventing shear. Protection from outside contaminants and further tissue injury. Control of bleeding and drainage. Increased patient comfort. Maintaining a moist environment. - CORRECT ANSWER Protection from outside contaminants and further tissue injury. Control of bleeding and drainage. Increased patient comfort. Maintaining a moist environment. 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. Tape should be pulled parallel to the skin in a direction away from the incision. Use caution to avoid tension on any drains that are present. While wearing clean gloves, remove the dressing layers all at one time and discard. 16 Wear sterile gloves to remove old dressing. - CORRECT ANSWER 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? Gauze dressing. Hemovac drain. Transparent dressing. Damp-to-dry dressing. - CORRECT ANSWER Damp-to-dry dressing The nurse is teaching the nursing assistive personnel (NAP) 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.) Using a turn sheet to reposition patients. Rubbing reddened bony prominences. Decreasing patients' fluid intake to decrease incidence of incontinence. Use of pillow bridging when needed. Positioning patient in the 30-degree lateral position. Turning patients at least every 2 hours. - CORRECT ANSWER Using a turn sheet to reposition patients. Use of pillow bridging when needed. Positioning patient in the 30-degree lateral position. Turning patients at least every 2 hours. How is the vacuum re-established after emptying a drain such as a Jackson-Pratt drain or Hemovac? By keeping the drain lower than the insertion site. 17 By turning the suction on. By "milking" the tubing. By compressing the drain reservoir. - CORRECT ANSWER 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. Cleanse wound. Use a separate swab for each cleansing stroke. Clean incision from top to bottom. Cleanse around drain by using a circular stroke starting near the drain and moving outward. Use sterile dry gauze to blot dry. Apply prescribed antiseptic ointment by using the same technique as for cleansing. Apply loose, woven gauze as contact layer. Place drain sponge (precut gauze) around drain. Apply additional layers of gauze as needed. Apply thicker woven pad (e.g., ABD or Surgipad). Dispose - CORRECT ANSWER 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? Paper tape. Adhesive tape. 20 Two to three days after surgery. The greatest risk of hemorrhage is during the first 24 to 48 hours after surgery or injury, indicating inadequate hemostasis. The nurse should monitor for decreased blood pressure and increased pulse rate and observe dressing and underneath the patient for any bloody drainage. - CORRECT ANSWER 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? Five to seven days after injury. Two to three days after injury. During the first 24 to 48 hours after injury. Up to 5 days after injury. - CORRECT ANSWER Two to three days after injury. A patient with lung cancer received radiation therapy to reduce the size of the tumor before a lobectomy (surgical removal of part of the lung). The patient is now being seen on home health services for packing of an abnormal passage between the patient's chest cavity and an opening on the patient's back. The nurse is aware the patient is at increased risk for: Edema. Fluid and electrolyte imbalance. Nerve damage with decreased sensation. 21 Hemorrhage. - CORRECT ANSWER 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? "When the dressing change is completed, be sure to wash your hands. A transparent dressing is beneficial because it maintains a moist environment, which aids wound healing; allows you to examine the wound without having to remove the dressing; and conforms well to body contours." "The old dressing may be removed while wearing clean gloves. Remove in direction of hair growth and toward the center. Remove disposable gloves pulling them inside out over the soiled dressing and dispose of properly." "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." "You will need to apply new gloves after you open your supplies and before you cl - CORRECT ANSWER "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 gloves and push the intestines back into the wound. 22 Assess the wound to determine the extent of evisceration. Instruct the patient to avoid looking at the wound. Apply sterile saline-soaked towels to the area. - CORRECT ANSWER Apply sterile saline-soaked towels to the area. Which of the following may indicate an increased risk for wound dehiscence? There is a small amount of serous drainage noted on the dressing. There is an increase in serosanguineous drainage from the wound. The patient holds a pillow over the abdomen whenever coughing. It is within the first 24 to 48 hours after surgery. - CORRECT ANSWER 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. An alcoholic. An adolescent who takes steroids for asthma. An elderly patient. - CORRECT ANSWER A diabetic obese patient who smokes. 25 A 30-year-old woman who had an episiotomy with childbirth. A patient receiving chemotherapy who has a surgical incision. A patient with peripheral vascular disease and an ulcer on the heel. - CORRECT ANSWER 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. Chronic wounds heal more efficiently in a dry, open environment, so leave them open to air when possible. Long-term steroid therapy diminishes the inflammatory response and speeds wound healing. Fat tissue heals more readily because there is less vascularization. - CORRECT ANSWER 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. The patient requests pain medication. Which of the following would be a correct explanation of what the nurse has assessed? These are expected findings for this postoperative period. The patient is becoming dependent on pain medication. 26 The nurse should observe the patient more closely for wound dehiscence. The patient is demonstrating signs of a postoperative wound infection. - CORRECT ANSWER 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. Wound dehiscence is most likely to occur during the first 24 to 48 hours after surgery. The nurse should administer cough suppressant to prevent wound dehiscence. The condition is an emergency that requires surgical repair. - CORRECT ANSWER 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: Has a drain. Is at greater risk for infection. Is at greater risk for wound dehiscence. 27 Is healing naturally. - CORRECT ANSWER Is at greater risk for infection. A postoperative diabetic patient had an exploratory laparotomy (incision in the abdomen) 5 days ago. The patient's history indicates obesity with a body mass index (BMI) of 32 and smoking 1 pack/day. Based on this information, the nurse understands the patient should be observed for: Developing a blood clot. Developing a fistula. Wound dehiscence. Hemorrhage. - CORRECT ANSWER Wound dehiscence. Which of the following are common sites for the development of pressure injuries? (Select all that apply.) Sternum. Heels. Sacrum. Lateral malleoli. Trochanters. Ischial tuberosities. - CORRECT ANSWER Heels. Sacrum. Lateral malleoli. 30 ANSWER She performs hand hygiene and removes the old dressing and begins to clean the injury with soap and water. A family member calls the nurse to ask for advice regarding their mother who has developed a "bedsore" on her right heel. 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 1. Stage 2. Stage 3. Stage 4. - CORRECT ANSWER Stage 2. The patient asks the nurse what the purpose is for his Hemovac drain. What is the nurse's best response? "To reduce the need for frequent dressing changes." "To provide suction to remove and collect drainage from your wound to help it heal." "To accurately determinine fluid loss and whether your fluids need to be increased." "To prevent infection and crust formation at the wound site." - CORRECT ANSWER "To provide suction to remove and collect drainage from your wound to help it heal." 31 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? "I should empty the drain when it is one-half to two-thirds full." "I should keep a record of how much drainage I empty." "If drainage suddenly stops, it means the drain is ready to be removed." "The bulb of the drain should remain compressed." - CORRECT ANSWER "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. If the patient complains of pain. When the drain is removed. If the nurse empties the drainage evacuator without applying sterile gloves. - CORRECT ANSWER 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: opens the plug on the port for emptying the drainage reservoir and drains the contents into the measuring container. 32 presses downward until the bottom and top of the Hemovac are in contact to reestablish the vacuum. holds the surfaces of the Hemovac together with one hand, cleans the opening and plug with an alcohol swab with the other hand, and immediately replaces the plug. empties the Hemovac drain, replaces the plug, and records the amount of drainage. - CORRECT ANSWER 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. Because a Penrose drain has to be frequently compressed to create a constant low-pressure suction. To prevent the tubing from migrating into the wound. To advance the tube as the wound heals. - CORRECT ANSWER 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)? Emptying a closed drainage container. Measuring the amount of drainage. 35 Packs wound tightly. Leaves contact or primary dressing dripping moist. When removing the old dressing the wife leaves the dressing dry, even when it sticks slightly. Pulls tape in direction toward wound when removing previous dressing. - CORRECT ANSWER 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. Switch to the black polyurethane (PU) foam. Keep the suction in the "off" position. - CORRECT ANSWER 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 creating a sterile field. 36 After the old dressing is removed and before cleansing the wound. After the old dressing is removed, after cleansing the wound, and before applying a new dressing. It is unnecessary to change gloves for chronic wounds. - CORRECT ANSWER 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? "If you are having difficulty with your dressing changes, we can see if the doctor will give you a referral to a home care agency." "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." "This type of dressing requires frequent changing because they do not stay in place." "You probably are applying it incorrectly, or perhaps you are just too anxious about having to perform the dressing change." "There are many options on the market. Why don't you try to use a non-adhesive-backed transparent dressing instead?" - CORRECT ANSWER "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." 37 A patient asks the nurse why the Montgomery ties are being used instead of regular tape. What is the nurse's best response? "Because Montgomery ties are nonallergenic." "Montgomery ties can be tied tighter, providing a more secure dressing and greater support of the wound." "Montgomery ties allow the wound to breathe." "Montgomery ties avoid frequent removal of tape, which is irritating to the skin during dressing changes." - CORRECT ANSWER "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 inquire about the patient's pain level. If there is a reported decrease in the level of pain, then the wound is constricting and negative pressure is being achieved. The nurse can ensure that there is no whistling noise at the wound site and that the wound V.A.C. has not triggered its alarm. 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. The nurse can ensure that the foam is in contact with the entire wound base, margins, and tunneled and undermined areas. - CORRECT ANSWER 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. 40 Occupation. Pain rated as a 7 on 0-10 pain scale. Time of day. - CORRECT ANSWER Moving from lying to standing position. Time of day. 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? (Select all that apply.) To provide the patient with reassurance that he or she is being cared for by a competent staff. To provide a set of vital signs to use for comparison during and after surgery. To determine whether the patient is "feeling funny" or &quotdifferent&quot. To verify the patient is not experiencing any complications that may contraindicate surgery or require intervention. To ensure the equipment is appropriately calibrated and functional. - CORRECT ANSWER 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. 41 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. Ask the NAP if the patient is nauseous. Document this as a normal finding in an elderly adult. Instruct the NAP to obtain a full set of vital signs. - CORRECT ANSWER Assess the patient s blood pressure. Which patient would it be appropriate for the nurse to delegate vital signs? Patient with recent complaint of headache. Patient transferred from ICU. New admission to the hospital. Elderly nursing home resident. - CORRECT ANSWER Elderly nursing home resident. Which person would be expected to have the lowest body temperature? An 80-year-old who walked half a mile. A child playing softball. A toddler who is febrile. 42 A 16-year-old who ran 1 mile. - CORRECT ANSWER 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?' "Since the soup was not hot, go ahead and take the patient's temperature." "Ask the patient not to eat, drink, or smoke for 20 minutes and then assess the patient's oral temperature." "Change to the red thermometer probe and take the patient's temperature rectally." "Take the patient's temperature using the axillary route and when you record the reading, add 1°F." - CORRECT ANSWER "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 newborn that requires continuous temperature monitoring. A pediatric patient who had tubes surgically placed in the ears. A tachypneic patient who is receiving oxygen by nasal cannula. A marathon runner who developed weakness during the race. - CORRECT ANSWER A tachypneic patient who is receiving oxygen by nasal cannula. 45 Infection. Room temperature. - CORRECT ANSWER Drinking a cold glass of water. Participation in physical therapy exercises. Infection. Room temperature. If a 52-year-old patient has a normal temperature, what range should the patient's temperature fall within? 35-36 °C (95-96.8 °F) 96.8-100.4 °F (36-38 °C) 96.8-98.6 °F (36-37 °C) 37-39 °C (98.6-102.2 °F) - CORRECT ANSWER 96.8-100.4 °F (36-38 °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 Chemical dot Tympanic Rectal electronic - CORRECT ANSWER Temporal artery 46 The task of pulse assessment could be delegated to the NAP for which of the following patients? (Select all that apply.) A radial pulse of a patient in the emergency room with chest pain. The temporal pulse of a child. An apical pulse of a patient who is to receive a cardiac drug. A radial pulse on a patient with a 1200 mL fluid restriction A femoral pulse following a lower leg amputation. - CORRECT ANSWER The temporal pulse of a child. A radial pulse on a patient with a 1200 mL fluid restriction Which of the following patients would be at risk for having an alteration in peripheral pulse? (Select all that apply.) An elderly patient with Type 1 diabetes who is otherwise healthy. A patient who is receiving bolus IV fluids. A patient with Alzheimer's disease. The patient who was just informed of a diagnosis of cancer. A patient with peripheral vascular disease. - CORRECT ANSWER A patient who is receiving bolus IV fluids. The patient who was just informed of a diagnosis of cancer. 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? 47 Check the carotid pulses one side at a time. Reassess the radial pulse for 30 seconds. Auscultate the apical pulse for quality and rate. Check the radial pulse on the opposite side. - CORRECT ANSWER Auscultate the apical pulse for quality and rate. What is the normal pulse range for an adult? 120 to 160 beats per minute. 60 to 100 beats per minute. 90 to 140 beats per minute. 50 to 80 beats per minute. - CORRECT ANSWER 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. True False - CORRECT ANSWER False For routine auscultation of the apical pulse, you should rely on the diaphragm side of the chest piece because it is designed to pick up higher-pitched heart sounds like that of the apical pulse. The bell side of the stethoscope should be used to assess heart sounds to identify murmurs. 50 Having a pain level rating at 7 on a scale of 0-10. Incurring a head injury from a motor vehicle accident. Using a bronchodilator prior to exercise. - CORRECT ANSWER Walking 1 mile briskly. Having an addiction problem with amphetamines/cocaine. Feeling anxious when taking a test. 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? Have another nurse assess the patient's respiratory rate. Document the inability to visualize inspiration and expiration. Move the patient's arm over their chest and feel the rise and fall of the chest. Remove the patient's gown for better visualization of the patient's chest. - CORRECT ANSWER 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? Auscultate the lung sounds, asking the patient to take a deep breath in through the nose and exhale slowly through the mouth. Assess the respirations while the patient is talking. Inform the patient when monitoring his or her respirations. 51 Continue to act as though taking the patient's pulse while discretely observing the rise and fall of the patient's chest. - CORRECT ANSWER 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 the patient's respiratory rate is less than 12 or greater than 20, the NAP counts the patient's respirations for 1 full minute. 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. When the patient's respiratory rate is irregular, the NAP counts the patient's respirations for 1 full minute. After taking the patient's pulse, the NAP continues to hold the patient's wrist, moving the arm across the patient's chest, and focuses on the patient's breathing. - CORRECT ANSWER 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 practice the technique of blood pressure measurement. To determine if there is a difference in the readings between the two arms. To verify the BP reading is 10 mm Hg higher in the dominant arm. 52 To assess for a pulse deficit and record this as a baseline measurement. - CORRECT ANSWER 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? An African-American patient with a systolic BP of 100. A football player with a diastolic BP of 94. An elderly patient with a systolic BP of 88. A pregnant woman with a diastolic BP of 67. - CORRECT ANSWER A football player with a diastolic BP of 94. For which patient should you avoid using a leg pressure cuff (thigh cuff) to assess BP? A patient who is a double arm amputee following a motor vehicle accident. A patient with a deep vein thrombosis (blood clot, usually in the lower extremities). A patient with a history of a right-sided cerebrovascular accident (stroke). A patient with an arteriovenous shunt located in the forearm for hemodialysis. - CORRECT ANSWER A patient with a deep vein thrombosis (blood clot, usually in the lower extremities). The student nurse is unsure of the BP measurement. What should the student nurse do first? 55 A patient who has an intermittent pulse oximetry reading of 95%. A patient with a heart rate of 64 beats per minute. - CORRECT ANSWER 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 necessary? "I will turn the continuous pulse oximetry alarms off at night so you can sleep." "I can give you a back massage to help you relax before bedtime." "If the finger clip is bothering you, I can attach a probe to your ear." "I will notify the nurse that you need your sleeping medication tonight." - CORRECT ANSWER "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? (Select all that apply.) Start oxygen at 2 liters per minute by nasal cannula. Reassess the patient's pulse oximetry. Place the patient in the high-Fowler's position. Answer,Have the NAP take the patient's vital signs. 56 Assess the patient's respiratory and cardiac status. - CORRECT ANSWER Reassess the patient's pulse oximetry. Place the patient in the high-Fowler's position. Assess the patient's respiratory and cardiac status. The nurse reads the following entry in a patient's health record. The patient has an order for SpO2 every 4 hours. Based on this information, what would be the nurse's best action?01/25/17 0800 Unable to obtain pulse oximetry reading. Attempted X2 fingers of each hand. Patient's fingers cool to touch. Patient states has artificial nails. Patient on 2 L oxygen per nasal cannula. Respirations nonlabored. C. Smith, N.A.P. Remove one of the patient's acrylic nails and reattempt obtaining the SpO2. Place the patient's hands under warm running water and reattempt the reading. Have the NAP use a different site, such as the ear lobe, to obtain the SpO2 reading. Nothing further, as the NAP has provided sufficient data regarding patient condition. - CORRECT ANSWER Have the NAP use a different site, such as the ear lobe, to obtain the SpO2 reading. A patient was diagnosed with a urinary tract infection. The patient has been drinking fruit juice and has increased his intake of fluids but has failed to take his antibiotic as prescribed because it caused gastric upset. Three days later, the patient presents to the clinic with fever, malaise, nausea, and vomiting. What might you suspect? 57 The patient probably has the flu. The patient may now have a systemic infection. The patient is displaying signs of a localized infection. The patient is experiencing an allergic response to his medication. - CORRECT ANSWER 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). Medical asepsis (clean technique). Droplet precautions. Standard precautions. - CORRECT ANSWER Surgical asepsis (sterile technique). The nurse is working in a busy emergency room. On entering station 1, the nurse dons a pair of clean disposable gloves. 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. Using medical asepsis. Using surgical asepsis. 60 A nurse is teaching infection control to a group of daycare workers. Which of the following should the nurse include in the instruction? Washing hands with soap and water is the only effective means for stopping the spread of germs. Immunizations help protect children from being susceptible hosts. Large containers of hand sanitizer should be made available for use when there is visible soiling. Toys are typically the reservoir of pathogen growth. - CORRECT ANSWER 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. The patient who is unable to shower without assistance. The patient with a history of a latex allergy. The patient who exercises daily in a swimming pool. - CORRECT ANSWER The patient who is receiving immunosuppressive medication. A nurse reads the following documentation in a patient's electronic health record: 92-year-old female complains of frequent nonproductive cough. States has been taking PO steroids as prescribed. Denies having received pneumonia vaccine. B. Jones, R.N. Based on this information, what factors place this patient at risk for being a susceptible host? (Select all that apply.) 61 Hospitalized. Nutritional status. Age. Gender. Vaccination status. Medical therapy. - CORRECT ANSWER 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.) Use sterile gloves if anticipating contact with nonintact skin. Artificial nails should be no longer than 0.625 cm (1/4 inch). If worn, fingernail polish should not be chipped. Cough hygiene practices should be followed. Gown and gloves are sufficient PPE for a splash risk. Always know a patient's susceptibility to infection. - CORRECT ANSWER If worn, fingernail polish should not be chipped. 62 Cough hygiene practices should be followed. Always know a patient's susceptibility to infection. When should you perform hand hygiene? (Select all that apply.) Correct! Before applying gloves to insert an IV. After documenting in the patient's electronic medical record. After moving a patient up in bed. Before assessing a patient's vital signs. Before touching clean linens. - CORRECT ANSWER Before applying gloves to insert an IV. After moving a patient up in bed. Before assessing a patient's vital signs. You are washing your hands in a sink with hand faucets. You first turn on the water and regulate the temperature to warm. You increase the water pressure to create a strong spray. You wet your hands, apply 1 teaspoon (5 mL) of soap, and rub your hands together vigorously, creating lather. You interlace your fingers and rub the palms and backs of the hands with a circular motion at least 5 times each. You keep your hands positioned with fingertips down and rinse the hands and wrists thoroughly. You turn off the faucet. You dry your hands with a paper towel. Which step(s) are incorrect? (Select all that apply.) The temperature of the water. 65 After the patient develops a skin tear and blood is on the nurse's hand. When the patient has been diagnosed with C. difficile. - CORRECT ANSWER 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: Washes her hands before and after removing clean gloves. Applies 3 to 5 mL of antimicrobial soap to hands wet with warm water. Takes the patient's blood pressure and leaves the room to document. Washes hands with plain soap and water when visibly dirty. Puts the patient's socks on, then begins to feed the patient. Moves the patient's IV pole by the bed and uses hand sanitizer. Has an uncovered cut on the back of the nondominant hand. - CORRECT ANSWER Takes the patient's blood pressure and leaves the room to document. Puts the patient's socks on, then begins to feed the patient. 66 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. Decrease the frequency of hand hygiene until healed. Wear clean latex-free gloves at all times. Be sure to rinse and dry hands thoroughly. Avoid excessive amounts of soap or antiseptic. - CORRECT ANSWER 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. The nurse opens the sterile commercial kit by pulling the outermost flap toward his body, followed by opening the remaining flaps. The nurse touches only the outer edge of the sterile field with his hands. The nurse adds sterile items to the sterile field by placing them on the field at an angle and never allowing the wrapper to touch the field. The nurse pours normal saline form a previously opened bottle in the patient's room into a sterile receptacle without splashing. Which action(s) in preparing a sterile field did the nurse perform incorrectly? (Select all that apply.) The nurse correctly prepared the sterile field. Opening the outermost flap. 67 Touching the outer edge of the sterile field. Adding sterile items to the field. Pouring a sterile solution. - CORRECT ANSWER Opening the outermost flap. Pouring a sterile solution. 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? Keep your intended work surface above waist level. Place the drape so the top half of the drape is over the top half of the work surface. You may grasp the outer 1-inch border of the drape without wearing sterile gloves. Place sterile items onto the sterile field at an angle. - CORRECT ANSWER Place the drape so the top half of the drape is over the top half of the work surface. 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. 70 Once sterile gloves are applied, the nurse moves the sterile gauze dressing to the center of the sterile field. The nurse continues with the procedure adding supplies to the sterile field and using each of them as needed. - CORRECT ANSWER The nurse asks the patient if he has ambulated in the hall today. The nurse is applying sterile gloves. Which series of steps would require correction? Perform hand hygiene. Examine glove package to determine if it is dry and intact. Open sterile gloves by carefully separating and peeling open the adhered package edges. Identify right and left glove. With thumb and first two fingers of nondominant hand, grasp edge of the cuff of the glove for the dominant hand. Touch only inside surface of the glove and pull the glove over the dominant hand, carefully working the thumb and fingers into the correct spaces. Gently let go of the cuff while preventing it from rolling up the wrist. Slide the fingers of the gloved hand underneath the second glove's cuff. Pull the glove over the fingers of the nondominant hand. Avoid touching exposed areas with the gloved hands. Hold gloved hands at sides of body, below waist level, until beginning the sterile procedure. - CORRECT ANSWER Hold gloved hands at sides of body, below waist level, until beginning the sterile procedure. Which of the following is a correct description of glove removal? 71 You pull the gloves off by the fingertips and discard them in a proper receptacle. You grasp the inside of one glove with the other gloved hand, pull the glove off, and discard it in a proper receptacle. The remaining glove is removed by placing the fingers of the bare hand outside the cuff, pulling the glove off, and discarding it in a proper receptacle. You grasp the outside of one cuff with the other gloved hand and pull the glove off, turning it inside out, and place it in gloved hand. Take fingers of bare hand and tuck inside remaining glove cuff against the skin. Peel glove off inside out and over the previously removed glove. Discard both gloves in receptacle. You slide the gloved fingers of the dominant hand under the inside cuff of the nondominant hand and pull the glove off and discard. Then you slide the fingers of the nondominant hand u - CORRECT ANSWER You grasp the outside of one cuff with the other gloved hand and pull the glove off, turning it inside out, and place it in gloved hand. Take fingers of bare hand and tuck inside remaining glove cuff against the skin. Peel glove off inside out and over the previously removed glove. Discard both gloves in receptacle. 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? Be sure to select appropriate size gloves. Gloves that are too small can tear more easily. Once sterile gloves are applied, the inside of the glove is still considered sterile. 72 Be sure to select appropriate size gloves. Gloves that are too large can impede your ability to pick up items and perform your task. If you touch a nonsterile item with your sterile gloved hands, you should remove the gloves and obtain a new pair. - CORRECT ANSWER 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. Purulent drainage. Edema. Difficulty breathing. Elevated temperature. - CORRECT ANSWER Skin redness. Itching. Edema. Difficulty breathing. An elderly patient is admitted for back surgery. She is now retired but her previous occupation was as a registered nurse. She reports that she is also allergic to morphine and penicillin. She has a history of five laminectomies (back surgeries) resulting from scoliosis as a child. She has three children who visit her. She 75 Use latex-free or synthetic gloves when gloves are necessary. Avoid use of alcohol-based hand rubs. - CORRECT ANSWER 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. A patient was hospitalized for surgical repair of a fractured hip. Upon admission her lungs were clear to auscultation and she was afebrile. Her discharge was delayed because she developed a fever and respiratory distress. A chest x-ray confirmed left lower lobe pneumonia. Which type of infection best describes what this patient has? A health care-associated infection. A drug-resistant infection. A local infection. A systemic infection. - CORRECT ANSWER A health care- associated infection. The nurse changes the dressing of your first patient with methicillin-resistant Staphylococcus aureus of the wound. The nurse discards the gloves and goes into the next room, where the nurse suctions a second patient s airway. According to the chain of infection, the mode of transmission is: The first patient's wound. The first patient. 76 The second patient's respiratory tract. The nurse. The second patient. Methicillin-resistant Staphylococcus aureus. - CORRECT ANSWER The nurse. The nurse has prepared a sterile field and added the necessary sterile items to the field. The nurse has applied sterile gloves and is waiting to assist the health care provider in performing a surgical procedure. The nurse keeps the sterile field in view and holds her hands down at her side, away from her clothing. While waiting, the nurse instructs the patient to avoid touching the sterile field and for the need to lie still. Which action made by the nurse is incorrect? Holding gloved hands at her side. The patient teaching. Failing to cover up the sterile field with a sterile drape while waiting. All actions are appropriate. - CORRECT ANSWER Holding gloved hands at her side. When are sterile gloves necessary? If blood or body fluids are present. When performing a sterile procedure. 77 When performing postmortem care. If the patient is placed on isolation. - CORRECT ANSWER When performing a sterile procedure. To apply sterile gloves, the nurse applied the first glove on the right hand. Where should the nurse pick up the remaining glove? At the top edge of the cuff. Anywhere, because the entire glove is sterile. Underneath the second glove's cuff. You should pick it up with your ungloved hand. - CORRECT ANSWER Underneath the second glove's cuff. The nurse is observing the NAP perform hand washing. During which step should the nurse intervene and provide further instruction? The NAP turns on the water and regulates the flow of water so that the temperature is warm and the force of the spray will not cause splashing. The nurse rinses the hands and wrists thoroughly, dries the hands, and uses a dry paper towel to turn off the hand faucet. The NAP applies 3 to 5 mL of detergent and rubs the hands together vigorously, lathering thoroughly. The NAP performs hand hygiene for at least 15 seconds, interlacing the fingers and rubbing the palms and back of hands with a circular motion at least 5 times each. 80 To wash hands with soap and water before and after caring for patients with C. difficile. - CORRECT ANSWER To wash hands with soap and water before and after caring for patients with C. difficile. An NAP asks what an example would be of using standard precautions. The nurse is correct to respond: Placing an "isolation precautions" sign on the patient's door to alert any visitors. Collecting a sputum specimen to determine if an infection is present. Wearing gloves and a mask whenever it is known that a patient has a communicable illness. Wearing clean gloves when emptying a bedpan. - CORRECT ANSWER 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 vehicle or route of transmission. The infectious agent. The reservoir. The susceptible host. - CORRECT ANSWER 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? 81 "Reducing the number of organisms and preventing their transfer is the goal of medical asepsis." "Alcohol-based hand rubs should be used often when caring for patients with Clostridium difficile." "Performing hand hygiene is an example of breaking the transmission link in the chain of infection." "Health care-associated infections are most likely to develop in the urinary and respiratory tract." - CORRECT ANSWER "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.) Using friction for 10 seconds in a vertical motion. Keeping the hands and forearms lower than elbows. Drying hands from wrists to fingers with a paper towel. Using hot water to rinse the hands after lathering. Turning the faucet off with a clean, dry paper towel. - CORRECT ANSWER Using friction for 10 seconds in a vertical motion. Drying hands from wrists to fingers with a paper towel. Using hot water to rinse the hands after lathering. A postoperative diabetic patient had an exploratory laparotomy (incision in the abdomen) 5 days ago. The patient's history 82 indicates obesity with a body mass index (BMI) of 32 and smoking 1 pack/day. Based on this information, the nurse understands the patient should be observed for: Developing a blood clot. Developing a fistula. Wound dehiscence. Hemorrhage. - CORRECT ANSWER Wound dehiscence. 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: has a drain. Is at greater risk for infection. Is at greater risk for wound dehiscence. Is healing naturally. - CORRECT ANSWER Is at greater risk for infection. Which of the following may indicate internal hemorrhage? (Select all that apply.) Distention or swelling of the affected body part. An elevated white blood cell count. A decreased blood pressure and increased pulse. 85 Identify contributing factors to pressure injury formation. (Select all that apply.) Malnutrition. Middle age. Decreased sensory perception/mobility. Anemia. Excessive sweating. Ethnic background. - CORRECT ANSWER Malnutrition. Decreased sensory perception/mobility. Anemia. Excessive sweating. The patient complains "It feels like the drain is pulling on my surgical site." What is the nurse's best action? Secure the drain above the incision to the dressing with tape and a safety pin and instruct the patient to keep the drain above the insertion site when ambulating, sitting, and lying 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. Instruct the patient that this is the normal sensation of having a drain. 86 Have the patient lie down and advance the drain further into the patient until the sensation is relieved and drainage is noted in tubing; secure a new dressing over insertion site of drain. - CORRECT ANSWER 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 is inappropriate to delegate to nursing assistive personnel (NAP)? Emptying a closed drainage container. Measuring the amount of drainage. Assessment of wound drainage. Reporting the amount on the patient's intake and output record. - CORRECT ANSWER Assessment of wound 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. Because a Penrose drain has to be frequently compressed to create a constant low-pressure suction. To prevent the tubing from migrating into the wound. To advance the tube as the wound heals. - CORRECT ANSWER Because drainage can be irritating to the skin and may cause skin breakdown. 87 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: opens the plug on the port for emptying the drainage reservoir and drains the contents into the measuring container presses downward until the bottom and top of the Hemovac are in contact to reestablish the vacuum. holds the surfaces of the Hemovac together with one hand, cleans the opening and plug with an alcohol swab with the other hand, and immediately replaces the plug. empties the Hemovac drain, replaces the plug, and records the amount of drainage. - CORRECT ANSWER empties the Hemovac drain, replaces the plug, and records the amount of drainage. When should wound drainage be cultured? When there is a change in color, amount, or odor of drainage. If the patient complains of pain. When the drain is removed. If the nurse empties the drainage evacuator without applying sterile gloves - CORRECT ANSWER When there is a change in color, amount, or odor of drainage. Which of the following is a correct sequence for changing a gauze dressing? 90 A fever. Sleep. Taking a narcotic. Postural drainage. - CORRECT ANSWER A fever. Which of the following, if exhibited by the patient, is a late sign of hypoxia? Restlessness. Anxiety. Eupnea. Cyanosis. - CORRECT ANSWER Cyanosis. Which of the following patients would have the greatest potential for an alteration in respiration? A 15-year-old boy with a migraine headache. A 44-year-old woman with anemia. A 19-year-old woman with diarrhea. A 32-year-old man with an earache. - CORRECT ANSWER A 44-year-old woman with anemia. An elderly woman is hospitalized with pneumonia and anemia and has a history of heart failure. She is weak and has a poor cough effort. Her current vital signs are temperature 100.2 °F (37.9 °C), 91 pulse 114, respiration 26, blood pressure 106/58. She has oxygen ordered at 2 liters by nasal cannula. Her oxygen saturation measures 88% when on room air, 93% with supplemental oxygen. She develops shortness of breath on any activity and eats little because it is difficult for her to eat and breathe at the same time. Which of the following are risk factors for this patient developing hypoxia? (Select all that apply.) Anemia. Tachycardia. Increased secretions with weak cough. Impaired cardiac function. Shortness of breath. Pneumonia. - CORRECT ANSWER Anemia. Increased secretions with weak cough. Impaired cardiac function. Pneumonia. 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 are indications of hypoxia. Confusion, disorientation, and altered consciousness are indications of hypoxia. 92 Increases in pulse, respiration, and blood pressure are indications of hypoxia. Having difficulty breathing and looking blue are indications of hypoxia. Infection and fever are indications of hypoxia. Bronchitis and chronic obstructive pulmonary disease are indications of hypoxia. - CORRECT ANSWER Restlessness and anxiety are indications of hypoxia. Confusion, disorientation, and altered consciousness are indications of hypoxia. Increases in pulse, respiration, and blood pressure are indications of hypoxia. Having difficulty breathing and looking blue are indications of hypoxia. The nurse is caring for a patient who underwent major abdominal surgery 24 hours ago. The 72-year-old male patient is weak and lethargic because of large doses of medication for pain control. After noting audible gurgling on inspiration and expiration, the nurse completes a respiratory assessment. Which assessment parameters indicate the need for oral suction? (Select all that apply.) Unusual restlessness. Gagging. Gurgling and adventitious lung sounds. 95 "I should be careful to avoid touching the back of the throat with the tip of the suction catheter." "I should encourage fluids to help keep secretions thin." - CORRECT ANSWER "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 elderly patient who had outpatient foot surgery. The middle-age man who is postoperative for knee arthroplasty. The patient who is postoperative for abdominal surgery. The patient who preoperatively practiced cascade coughing. - CORRECT ANSWER The patient who is postoperative for abdominal surgery. Which of the following patients should be assessed for a worsening clinical situation? The chronic obstructive pulmonary disease (COPD) patient whose pulse oximetry remains the same after oropharyngeal suctioning. The patient with absence of adventitious lung sounds on inspiration and expiration. The patient who demonstrates less drooling after being suctioned. The patient with presence of blood in the secretions. - CORRECT ANSWER The patient with presence of blood in the secretions. 96 Which of the following patients may likely require oropharyngeal suctioning? (Select all that apply.) Correct! A patient who had maxillofacial surgery. A patient who had trauma to the mouth. A patient with impaired swallowing from neurological injury. A patient who has been diagnosed with lung cancer. A patient with an artificial airway who requires oral hygiene. A patient who has a nasogastric feeding tube. - CORRECT ANSWER 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. 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. preventing the development of atelectasis. 97 The purpose of preoxygenating the patient, whether intubated or not, is to compensate for the loss of oxygen during the procedure. - CORRECT ANSWER preoxygenating the patient. offsetting the volume of oxygen lost during the suction procedure. compensating for the interruption in mechanical ventilation 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.) The nurse applies a sterile glove to the dominant hand and a nonsterile glove to the nondominant hand. 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 and then discards the suction catheter inside the gloves into an appropriate receptacle. The nurse picks up the catheter with the dominant hand, then picks up the connecting tubing with the nondominant hand and secures the catheter to the tubing. - CORRECT ANSWER 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 and then discards the suction catheter inside the gloves into an appropriate receptacle. Which of the following statements regarding nasotracheal suctioning are true? (Select all that apply.)