Exam 2 - Questions Flashcards
ATI Skills - Nutrition
Which of the following factors is most likely to have had a negative image on this client’s overall nutritional state?
a. Age
b. Limited finances
c. Lactose intolerance
Limited finances
ATI Skills - Nutrition
Which of the following suggests POOR NUTRITION?
a. The client has sustained a fx
b. The client has acne on her face and upper chest
c. The client weights 6 lbs less than her ideal body weight [IBW]
The client weights 6 lbs less than her ideal body weight [IBW]
ATI Skills - Nutrition
Females in the client’s age group should be counseled to do which of the following?
a. Increase protein consumption from a variety of sources
b. Divide their daily caloric intake among six meals
c. Take daily calcium and iron supplements
Take daily calcium and iron supplements
To best support good bone health and to offset the loss of iron via menstruation, these supplements are generally recommended for females between the ages of 20 and 60
ATI Skills - Nutrition
Which of the following assessment findings is likely to have a negative, long-term effect on a client’s nutritional status?
a. Poor dental health
b. Family hx of obesity
c. Preference for vegetarian lifestyle
Poor dental health
Dental caries, gum disease, and tooth loss can all contribute to ineffective or painful chewing, leading to decrease in nutritional intake
ATI Skills - Nutrition
You should teach the client that, to facilitate healing of her fracture, she should increase intake of which of the following?
a. Folic acid
b. Vitamin C
c. Thiamine
Vitamin C
Vitamin C (ascorbic acid) aids in tissue building and many metabolic reactions, such as wound and fracture healing
Folic acid - [Folate (synthetic form: folic acid) is required for hemoglobin and amino acid synthesis, cellular reproduction, and prevention of neural tube defects in utero. It has no direct relationship on bone healing]
Thiamine - [Thiamin (vitamin B,) is necessary for proper digestion and peristalsis and providing energy for smooth muscles, glands, the central nervous system, and blood vessels. It has no direct relationship on bone healing]
ATI Skills - Nutrition
Which of the following relates to the NUTRITIONAL NEEDS of an older adult client?
a. Vitamin supplementation becomes increasingly essential in advancing age
b. Older adults require fewer calories per day than younger adults do
c. Dairy products become more difficult to digest as age advances
Older adults require fewer calories per day than younger adults do
It is generally true that advancing age results in a slower metabolic rate, thus lowering daily caloric requirements
ATI Skills - Nutrition
Which of the following findings is likely to have had a negative impact on the client’s nutritional status?
a. Osteoarthritis in wrists and hands
b. Allergy to wheat
c. History of GERD
Osteoarthritis in wrists and hands
This disorder results in painful and limited movement in the hands and fingers, impairing the client’s ability both to prepare and to eat food. This could likely result in a diet that does not support a healthy nutritional statu
ATI Skills - Nutrition
The client may experience a decrease in appetite during recovery because of which of the following?
a. Exacerbations of GERD
b. Impaired bone healilng
c. Decreased activity
Decreased activity
The partial immobility related to the fracture is likely to result in a decrease in his usual physical activity level, thus decreasing his appetite and his need for calories
ATI Skills - Nutrition
After the client emphasizes his need to remain as independent as possible, you should suggest that he ensure maintenance of his nutritional status by doing which of the following?
a. Cooking ample amounts of nutritious foods
b. Using local resources for delivering meals to his home
c. Asking neighbors to share their meals with him
Using local resources for delivering meals to his home
ATI Skills - Nutrition
When visiting the client approximately 3 weeks after discharge, the home health care nurse reports concerns about the client’s nutritional status to the provider based on which of the following findings?
a. The client has several open bags of cookies and soda cans about his living room.
b. The client has a noticeable red rash on his hands, arms, and chest.
c. The client states, “Tell me again why you are here.”
The client states, “Tell me again why you are here.”
ltered mental status, in this case confusion and poor short-term memory, is a possible indication of poor nutrition. In addition, altered mental status can further impair the client’s ability to ingest sufficient nutrients
ATI Skills - Nutrition
Which of the following problems has the highest priority when addressing the introduction of food and liquids for this client?
a. Inability to self-feed
b. Impaired communication
c. Aspiration risk
Aspiration risk
This problem has the highest priority when initiating feeding in a client who has dysphagia because aspiration affects the client’s airways. The client’s ability to breathe takes priority over other concerns
ATI Skills - Nutrition
Which of the following diets is appropriate for this client?
a. Pureed foods and thickened liquids
b. Ground or diced foods with full liquids
c. Low-fiber, easily digested foods and liquids
Pureed foods and thickened liquids
This option best addresses the client’s risk for aspiration. Semisolid or medium consistency foods, such as cooked cereal, and thickened liquids are easiest to swallow and generally safest
ATI Skills - Nutrition
To minimize the client’s risk for injury related to eating, you should do which of the following?
a. Remind him to chew his food well before attempting to swallow
b. Transfer him to a chair for meal
c. Keep HOB elevated for at least 30 minutes after meals
Transfer him to a chair for meal
Ensuring that the client is in a sitting (high Fowler’s) position helps minimize the client’s risk for aspiration
a. Remind him to chew well before swallowing - [This client is having difficulty chewing his food well due to right-sided weakness. A reminder to do something he cannot do is likely to cause anxiety and frustration and possibly worsen his risk for aspiration]
c. Keep HOB elevated for 30 min after eating -[Placing the client in a semi-Fowler’s position for at least 60 minutes after meals is generally recommended]
ATI Skills - Nutrition
Which of the following is likely to be the most reliable indicator that the client is at risk for poor nutrition?
a. Bowel movement every 3 days
b. Serum albumin levels of 3.2 d/dL
c. Unwillingness to eat meat
Serum albumin levels of 3.2 d/dL
ATI Skills - Nutrition
Which of the following points should you stress to the client’s family to minimize his risk for aspiration at home?
a. Offering the client frequent sips of water between feedings
b. Having the client tilt his head
c. Checking the client’s cheeks for pocketed food
Checking the client’s cheeks for pocketed food
Pocketing or storing food in the cheeks rather than swallowing it is common among clients who have dysphagia, and it increases the risk of aspiration
a. Offering the client frequent sips of water between feedings - Aspiraiton is MORE likely with thin liquids than with thickened liquids
ATI Skills - NG Tubes
Which is the appropriate response when the client asks the nurse why he needs the nasogastric tube?
a. “It removes the contents of your stomach so that you can go home earlier”
b. “It will help relieve your manifestations of vomiting and bloating”
c. “You need the tube to correct the blockage in your intestine”
“It will help relieve your manifestations of vomiting and bloating”
ATI Skills - NG Tubes
The nurse explains to the client that the provider has prescribed a double-lumen gastric sump tube rather than another type of nasogastric tube for which of the following reasons?
a. It allows for the removal of stomach contents
b. It is the tube most often used for gastric decompression
c. It can be used for continuous suctioning
It can be used for continuous suctioning
ATI Skills - NG Tubes
The nurse inserts the nasogastric sump tube without complications. After the nurse confirms, proper tube placement, the nurse connects the tube to low continuous suction. After the first hour, the nurse sees 100 mL of grassy green aspirate in the collection canister. During the next 2 hours, the output in the collection canister remains at 100
mL
Which of the following is the appropriate action for the nurse to take?
a. Continue to observe for gastric output by rechecking the level in another hour
b. Withdraw the tube 5 cm to see if the output increases
c. Check the function of the suction source and its connection to the NG tube
Check the function of the suction source and its connection to the NG tube
ATI Skills - NG Tubes
Which of the following interventions should the nurse complete when assessing the patency of tube?
a. Flush the tube with 10 to 20 mL of water.
b. Instill 5 mL of digestive enzymes with sodium bicarbonate.
c. Attach a 60 mL syringe to the proximal end and aspirate.
Flush the tube with 10 to 20 mL of water
ATI Skills - NG Tubes
Which of the following positions should the nurse place the client prior to beginning lavage, to facilitate pooling and removal of gastric contents?
a. Right lateral with head of bed up about 20 degrees
b. Left lateral with head of bed down about 15 degrees
c. Recumbent with head of bed down about 30 degrees
Left lateral with head of bed down about 15 degrees
ATI Skills - NG Tubes
A client returned from surgery 3 days ago following a partial colectomy with anastomosis for Crohn’s disease. The nasogastric tube inserted in surgery was
removed yesterday. On examination, the client’s abdomen is distended and reports feeling nauseated. The nurse is concerned about the potential for postoperative large bowel Obstruction. After talking with the surgeon, nasogastric decompression is prescribed to relieve the nausea and gastric distension. While preparing for nasogastric intubation, the nurse reviews the complications of nasogastric decompression.
Which of the following electrolyte imbalances can occur for a client who has NG decompression for a paralytic ileus?
a. Hyperchloremia
b. Hyponatremia
c. Hypokalemia
Hypokalemia
Since gastric contents are rich in potassium, chloride, and hydrogen ions, nasogastric decompression can result in several electrolyte disturbances. Potassium is one of the major cations removed by decompression while chloride is the major anion. With the body’s normal amount of serum potassium maintained within a small range, there is little tolerance for fluctuations, so hypokalemia is the most common electrolyte disturbance associated with nasogastric decompression
ATI Skills - NG Tubes
he client wishes to know about each step of the procedure. The nurse carefully explains each step, after which the client states, “If it will make my abdomen feel better and take away the nausea, then let’s do it.” After reviewing the client’s laboratory values and verifying that there are no contraindications for the procedure, the nurse prepares for nasal intubation.
While advancing the tube past the nasopharynx, the nurse should ask the client to do which of the following actions?
a. Lie in a left lateral position with the head of the bed lowered
b. Tilt the head forward on to the chest.
c. Take a deep breath and hold it.
Tilt the head forward on to the chest
ATI Skills - NG Tubes
After the nurse has verified the correct tube placement and anchored the tube in place, the nurse connects it to low intermittent suction.
Low intermittent suction is most often used because it does which of the following?
a. Prevents tube occlusion, especially with viscous gastric fluids
b. Minimizes the risk of damage to the gastric mucosa
c. It lowers the risk of damage to the gastric mucosa by allowing periods of rest and time for the tube to migrate away from the gastric tissue
d. Is the most efficient method of withdrawing gastric contents
Minimizes the risk of damage to the gastric mucosa
Low intermittent suction can be used with any type of nasogastric tube
ATI Skills - Enteral Tube Feeding
A 16-year-old client is being considered for major oral surgery following a motor-vehicle crash that resulted in extensive damage to her lower jaw. Her recovery from the surgery will interfere with her oral intake for approximately 3 weeks.
With the client’s parents present, you prepare to educate the client about the
proposed alternative form of feeding involving intermittent enteral tube feedings.
You explain to the client that the provider has prescribed a small-bore nasogastric tube for which of the following reasons?
a. It does not cause discomfort upon insertion
b. It is best suited for short-term enteral feeding therapy
c. Tube placement can be verified by injecting air through the tube and auscultating for gurgling sound
It is best suited for short-term enteral feeding therapy
small-bore NG tube is appropriate for therapy lasting LESS THAN 4 WEEKS
ATI Skills - Enteral Tube Feeding
You review possible complications that can occur with enteral tube feeding. Nursing interventions to decrease the likelihood of these complications include which of the following?
a. Evaluating tube feeding tolerance by checking gastric residual every 8 hr and diluting the feeding for residual greater than 100 mL
b. Identifying a displaced tube by obtaining a gastrointestinal aspirate for pH measurement
c. Preventing diarrhea by consulting with the dietician to change the formula to one that does not contain fiber
Identifying a displaced tube by obtaining a gastrointestinal aspirate for pH measurement
ATI Skills - Enteral Tube Feeding
Following insertion of the small-bored feeding tube, you confirm placement
After reviewing the provider’s prescriptions, you hang the feeding bag and tubing on the pole. Prior to initiating the feeding, which of the following actions should you take?
a. Fill the bag with enough formula to last over a 4- to 8-hr period
b. Keep formula in the refrigerator until just before feeding begins
c. Notify the provider if bowel sounds are decreased prior to starting tube feeding.
Fill the bag with enough formula to last over a 4- to 8-hr period
filling the bag with only enough formula for 4 hr will DECREASE THE RISK OF BACTERIAL CONTAMINATION
ATI Skills - Enteral Tube Feeding
You begin the continuous feeding using a feeding pump. Management of continuous enteral feeding includes which of the following?
a. Changing the feeding bag every 72 hr
b. Flushing the tube with 30 mL of water every 4 hr to prevent clogging
c. Checking pH every 2 hr
Flushing the tube with 30 mL of water every 4 hr to prevent clogging
ATI Skills - Enteral Tube Feeding
A 46-year-old man is experiencing nausea, vomiting, and intense epigastric pain. He is diagnosed with acute pancreatitis, so the provider orders an NG tube insertion. You must prepare and insert the tube, manage it, and remove it after the client’s condition improves
Which of the following actions should you perform first in preparation for inserting the NG tube?
a. Lubricate the end of the tube with water-based jelly.
b. Evaluate the patency of the client’s nares.
c. Ask the client to extend his neck back against the pillow.
Evaluate the patency of the client’s nares
ATI Skills - Enteral Tube Feeding
To facilitate the insertion of the NG tube, which of the following actions should you take?
a. Instruct the client to swallow during tube insertion.
b. Have the client extend head after the tube passed through nasopharynx.
c. Apply gentle force when meeting resistance.
Instruct the client to swallow during tube insertion
ATI Skills - Enteral Tube Feeding
To minimize the transmission of microorganisms while inserting the NG tube, which of the following actions should you take?
a. Wear clean gloves during the procedure.
b. Obtain a culture of the nasal cavity prior to insertion.
c. Suction the client’s nose and mouth prior to insertion
Wear clean gloves during the procedure
ATI Skills - Enteral Tube Feeding
To determine the length of tube that will achieve the proper insertion depth, which of the following actions should you take?
a. Measure the distance from the client’s naris to his ear lobe to the tip of his xiphoid process.
b. Mark the location on the tube that is 1 ½ times the distance from the client’s nose to his xiphoid process.
c. Use a disposable ruler to measure from the client’s nose to umbilicus.
Measure the distance from the client’s naris to his ear lobe to the tip of his xiphoid process.
ATI Skills - Enteral Tube Feeding
After initial verification of the NG tube’s placement by x-ray, you should also verify placement by performing which of the following actions?
a. Assessing for normal bowel sounds
b. Auscultating while flushing 30 mL of air through the tube to hear swooshing sounds
c. Testing the pH of an aspirated fluid sample from the NG tube
Testing the pH of an aspirated fluid sample from the NG tube
The only true, reliable method of confirmation is an X-RAY! Many policies require using secondary methods of verification, one of which is typically the pH of NG aspirate
a. Assessing for normal bowel sounds [normal bowel sounds do NOT assist in determining NG placement]
b. Auscultating while flushing 30 mL of air through the tube to hear swooshing sounds [unreliable - esp. If someone has a small-bore tube inserted]
ATI Skills - Enteral Tube Feeding
You elevate the head of the client’s bed, place a disposable pad over the client’s chest, and provide the client with facial tissues and an emesis basin. You verify tube placement and flush it with 30 mL of water. You remove the anchoring device and ask the client to hold their breath to facilitate the removal of the tube.
To minimize the risk of trauma and discomfort for the client when removing the NG tube, which of the following actions should you take?
a. Slowly rotate the tube 180 degrees while pulling back on it.
b. Use the pull-pause method to remove the tubing gradually.
c. Fold the tube onto itself while quickly pulling back on it.
Fold the tube onto itself while quickly pulling back on it
folding the tube prevents tube contents from draining into the client’s oropharynx + quick removal minimizes discomfort
ATI Skills - Enteral Tube Feeding
Your 81-year-old client cannot take oral feedings due to the effects of a CVA. You must administer nutritional support and medications safely and appropriately through an NG tube
Which of the following actions helps ensure the safe administration of enteral formula intermittently via NG tube?
a. Identifying the correct client by having client state their provider’s name
b. Ensuring proper NG tube placement according to facility policy
c. Adding a small amount of blue dye to the formula
Ensuring proper NG tube placement according to facility policy
ATI Skills - Enteral Tube Feeding
Because this client is at high risk for aspiration, which of the following actions should you take?
a. Administer half-strength enteral formula.
b. Position the client in a left lateral position.
c. Elevate the head of the client’s bed to a minimum of 30 degrees
Elevate the head of the client’s bed to a minimum of 30 degrees
ATI Skills - Enteral Tube Feeding
To minimize the transmission of micro-organisms during the enteral formula feeding through the NG tube, which of the following actions should you take?
a. Cleanse the top of the canned formula with an alcohol swab before opening it.
b. Wear a personal protective gown and mask during the procedure.
c. Change the syringe or feeding bag every 48 hr
Cleanse the top of the canned formula with an alcohol swab before opening it
ATI Skills - Enteral Tube Feeding
You use a 60 mL syringe with its plunger removed to administer the enteral feeding.
You attach the syringe to the NG tube and clamp it closed. After cleaning the top of the formula container with a disinfectant, you open the container and pour the prescribed amount of formula into the syringe.
To regulate the flow of enteral formula through the NG tube, you open the tubing and do which of the following?
a. Adjust the syringe height to adjust the rate of feeding flow.
b. Apply gently pressure with the syringe’s plunger to direct the formula through the tube.
c. Introduce more formula gradually into the syringe as the fluid level drops.
Adjust the syringe height to adjust the rate of feeding flow
ATI Skills - Enteral Tube Feeding
After you have introduced the prescribed amount of enteral formula through the NG tube, you promote patency of the tube by doing which of the following?
a. Clamping the NG tube
b. Applying a clean cap to the open end of the NG tube
c. Flushing the NG tube with 30 to 60 mL of water
Flushing the NG tube with 30 to 60 mL of water
ATI Skills - Enteral Tube Feeding
After completing the enteral feeding, you should minimize the client’s risk for aspiration by doing which of the following?
a. Auscultating the abdomen for the presence of bowel sounds
b. Ensuring proper NG tube placement according to the facility’s policy
c. Keeping the head of the client’s bed elevated at 30 to 45 degrees
Keeping the head of the client’s bed elevated at 30 to 45 degrees
ATI Skills - Enteral Tube Feeding
The provider prescribed three oral medications to be administered to the client via the NG tube. Following the six rights of medication administration, you prepare to instill the medication into their NG tube
To maintain the patency of the NG tube when administering medication, which of the following actions should you take?
a. Thoroughly crush and mix all the medication together, adding water as needed.
b. Add each medication directly to the enteral formula, blending it together thoroughly.
c. Flush the tubing with at least 15 mL of water before the first c medication, between each medication, and after the last medication.
Flush the tubing with at least 15 mL of water before the first c medication, between each medication, and after the last medication
ATI Skills - Bowel Elimination
Today you are working in an outpatient women’s health clinic. The young adult client you are caring for will have an elective gynecological outpatient procedure next week. The provider has prescribed a hypertonic enema for bowel preparation. You’ll
teach the client how to self-administer the enema in preparation for the procedure.
You plan to assess the patient by asking if she has ever had an enema before. She replies, “I feel a little uncomfortable, I’m not going to lie. Do I have to do it myself, or can I just do it the morning at the clinic?”
Which of the following responses should the nurse make?
a. “It’s a very simple procedure that people do at home all the time.”
b. “If you don’t give yourself the enema, the provider cannot perform the procedure.”
c. “It appears that you are uncomfortable with administering yourself an enema.”
“It appears that you are uncomfortable with administering yourself an enema.”
ATI Skills - Bowel Elimination
The client explains that the process of self-administration is making her anxious, primarily due to her lack of knowledge and experience but also due to her feelings of modesty about bowel elimination. During your assessment, you determine that she has no previous experience with enemas and has some questions. You explain the purpose of the enema and also the rationale for administering the enema the
night before the procedure. While explaining how to self-administer the hypertonic enema, you encourage her to continue to ask questions and express her feelings. As you teach her, you notice that she seems less anxious. At the conclusion of your instruction, you evaluate the effectiveness of your teaching by confirming that she understands how to self-administer the enema.
Which of the following responses indicates that the client understands how to retain the enema before defecation?
a. “I will try to retain the solution for 5 to 10 minutes.”
b. “I will try to retain the solution for 30 to 45 minutes.”
c. “I will try to retain the solution for 1 to 2 hours.
“I will try to retain the solution for 5 to 10 minutes.”
ATI Skills - Bowel Elimination
Today you are working on a medical-surgical unit. The client you are caring for will have bowel surgery the following day. You enter the client’s room just as the surgeon is discussing the planned surgery and bowel preparation with the client. After the surgeon leaves, the client states, “My doctor says I need to have enemas until clear this evening. I’m not sure I like the sound of that.” You respond therapeutically, explaining that you’ll check his medical record to verify the surgeon’s prescription and then you’ll return to discuss the procedure with him.
Which of the following is used to administer enemas until clear?
a. Tap water
b. Hypertonic enema
c. 0.9% sodium chloride
0.9% sodium chloride
ATI Skills - Bowel Elimination
After obtaining the appropriate supplies, you enter the client’s room to prepare to administer the enema. You wash your hands, check the client’s identification, close the curtains around the bed for privacy, and ask the client if he’d like you to explain any aspect of the procedure again before beginning. The client states that he has no further questions, so you assist him into the left side-lying Sims’ position with his right knee flexed. You place a waterproof pad beneath his buttocks. You are now ready to begin the first enema.
To promote the client’s comfort during the administration of the enema solution, which of the following actions should you take? (Select all that apply.)
a. Preheat the normal saline solution to lukewarm prior to administration.
b. Lubricate the tip of the rectal tube before inserting it into the client’s anus.
c. Point the tip of the enema tube toward the client’s umbilicus while inserting it.
d. Insert the tip of the tube approximately 5 to 7 inches into the rectum.
e. Have the client bear down as you insert the tube and start the flow of solution.
a. Preheat the normal saline solution to lukewarm prior to administration.
b. Lubricate the tip of the rectal tube before inserting it into the client’s anus.
c. Point the tip of the enema tube toward the client’s umbilicus while inserting it.
ATI Skills - Bowel Elimination
You administer the first enema and the client is able to retain it well. After observing the returns, you determine that you must administer a second enema. Following administration of the second enema, the client calls you to his room after he has defecated using the commode so that you can evaluate his response to the enema by observing the returns for the color, consistency, and amount of stool and liquid.
You evaluate that the enemas have had the desired effect when you find which of the following?
a. Large amount of slightly discolored solution with no solid fecal matter
b. Large amount of clear solution with several pea-sized flecks of stool
c. Large formed stool in a large amount of clear solution
Large amount of slightly discolored solution with no solid fecal matter
ATI Skills - Bowel Elimination
Today you are working in an extended care facility. You have a certified nursing assistant assigned to your team today. One client on your team is on bed rest and has developed constipation. In addition to stool softeners and a high-fiber diet, the provider has prescribed a soapsuds enema. You plan to delegate the task of administering the enema to the nursing assistant, but first you have to verify that she is knowledgeable about performing this skill. When you ask how she would position the client for administering the enema, she replies, “I was taught to put patients in Sims’ position when administering an enema.”
How should the nursing assistant respond when you ask them to describe how they will place the client in the Sims’ position?
a. On the abdomen with a pillow positioned under the pelvis
b. Lying on the right side with knees drawn up to the chest
c. On the left side turned toward the abdomen with the right leg drawn up
On the left side turned toward the abdomen with the right leg drawn up
ATI Skills - Bowel Elimination
You review the remainder of the items that the nursing assistant has brought to the room and make sure that all the required equipment is on hand before she prepares to begin the enema. You ask her if she has any additional questions, and she replies, “The last time I gave an enema, the client had really painful cramping. I not sure what I am supposed to do in that situation.”
Which of the following actions should the nursing assistant take first if the client reports cramping?
a. Place the client on the bedpan to evacuate the enema solution immediately.
b. Remind the client that cramping can occur during enema administration.
c. Lower the height of the solution bag to slow the instillation rate.
Lower the height of the solution bag to slow the instillation rate
ATI Skills - Urinary Elimination
Does urinary catheterization ALWAYS require a provider’s order?
Yes
No
YES
ATI Skills - Urinary Elimination
What are the common manifestations of UTI?
Elevated white blood cell count
Urine with a pungent odor
Increased sediment in the urine
Confusion or alteration in mental status
Change in urination pattern
Fever
ATI Skills - Urinary Elimination
What strategies should be used to help keep clients from developing CAUTIs (catheter-associated UTIs)?
Always use sterile technique when placing Foley catheter
Give appropriate & thorough perineal care
Assess equipment carefully to ensure a closed system
Intervene to prevent prolonged catheter use
ATI Skills - Urinary Elimination
What are the indications for urinary catheterization?
Inability to void because of retention
The need for close hemodynamic monitoring
Post-surgical recovery
Standards of practice encourage the removal of a catheterization ASAP
ATI Skills - Urinary Elimination
You have cleansed the urethral meatus three times on your elderly female patient and are about to insert the catheter. Your client repositions herself, causing the labia to close briefly over the urethra.
Which of the following should you do next?
a. Restrain the client and start the procedure over, using a new sterile catheterization kit.
b. Ask an assistive personnel to help and then apply sterile gloves; re-cleanse the meatus with sterile antiseptic.
c. Quickly insert the catheter before further contamination can occur.
Ask an assistive personnel to help and then apply sterile gloves; re-cleanse the meatus with sterile antiseptic
ATI Skills - Urinary Elimination
After inserting the catheter, you do not observe any return of urine. Abdominal palpation suggests that your client’s bladder remains distended.
Which of the following actions should you take next?
a. Remove the catheter and repeat the procedure with a sterile, large-diameter catheter
b. Slowly advance the catheter tip while gently rotating the tubing
c. Apply gentle pressure to the distended abdomen and observe for urine return
Slowly advance the catheter tip while gently rotating the tubing
ATI Skills - Urinary Elimination
Now that you have inserted the urinary catheter into the bladder and inflated the balloon, you must obtain a urine sample to send to the laboratory for urinalysis, culture, and sensitivity.
The correct steps for obtaining a urine sample from a closed system are which of the following?
a. Disconnect the collection bag from the drainage tubing, cleanse A the end of the tube with an aseptic solution, and allow urine to flow from the tube into a specimen bottle.
b. Collect 5 to 10 mL of urine from the collection bag into a sterile specimen container before emptying urine from the collection bag into the commode.
c. Allow all the urine to collect in the bag and then empty the bag and collect urine from the collection port.
Collect 5 to 10 mL of urine from the collection bag into a sterile specimen container before emptying urine from the collection bag into the commode
ATI Skills - Urinary Elimination
You are in the process of providing routine catheter care for this client 2 days after admission. As you start to cleanse the tissue surrounding the catheter, you note that the area is wet and erythematous. It appears that urine is leaking from around the catheter’s insertion site. You also note some bladder distention.
Which of the following actions should you take first?
a. Deflate the balloon and remove the catheter.
b. Call the provider and notify the charge nurse of your findings.
c. Examine the catheter and the drainage tube along their entire path
Examine the catheter and the drainage tube along their entire path
ALWAYS EXAMINE / ASSESS / INSPECT BEFORE ANY FURTHER INTERVENTIONS
LEAST INVASIVE FIRST
ATI Skills - Urinary Elimination
Your client’s provider orders daily bladder irrigation to clear the urine of bacterial debris and blood clots. You follow protocol and attach a Y tube to the catheter and start bladder irrigation. The irrigant solution flows easily into the bladder, but shortly after you begin, the client reports lower abdominal pain and cramping.
Which of the following actions should you take next?
a. Slow the irrigant solution and continue the procedure.
b. Stop the procedure and evaluate for an occlusion.
c. Assure the client that some discomfort is expected with this procedure.
d. Hasten the procedure by increasing the rate of flow of the irrigant.
Stop the procedure and evaluate for an occlusion
ATI Skills - Urinary Elimination
Today you are working on a med-surg unit. Each of your four clients has an indwelling urinary catheter. You will not receive report on each client.
Which of the following clients should you manage first?
a. The client with a spinal cord injury who has sediment in their urinary drainage bag.
b. The client newly admitted to the unit after kidney surgery with bloody urine output.
c. The client that is reporting pressure around their bladder.
d. The client that is scheduled to be discharged home today with a leg bag.
The client newly admitted to the unit after kidney surgery with bloody urine output
ATI Skills - Urinary Elimination
Now that you have determined that you must see your postoperative client first, you enter their room. Immediately, the client reports severe abdominal pain.
Which of the following nursing assessments should you perform?
a. Obtain orthostatic blood pressures
b. Palpate bilateral pedal pulses
c. Auscultate and palpate the abdomen
d. Measure the client’s jugular venous pressure
Auscultate and palpate the abdomen
The client reports severe abdominal pain and may be hemorrhaging.
For this client, the hemorrhage is most likely in the abdominal cavity where the surgery took place, so auscultate the abdomen immediately for decreased bowel sounds and palpate it for increased firmness and discomfort. You might not find other objective signs of hemorrhage, such as tachycardia, hypotension, decreased urine output, agitation, and pale or diaphoretic skin until the client’s hemoglobin is well below 10.0 gm/dL.
a. Obtain orthostatic blood pressures - obtaining orthostatics is appropriate when you suspect dehydration or to assess fluid status
b. Palpate bilateral pedal pulses - palpating pedal pulses helps you detect ischemia of the lower extremities
ATI Skills - Urinary Elimination
The client’s abdomen is distended and firm without active bowel sounds. You suspect internal hemorrhage and call the surgeon immediately. The client is transferred back to the surgical suite. You will now receive additional information on your other three clients.
Which of the following clients will you see next?
a. The client that is reporting pressure around their bladder.
b. The client that is scheduled to be discharged home today with a leg bag.
c. The client with a spinal cord injury who has sediment in their urinary drainage bag.
The client that is reporting pressure around their bladder
ATI Skills - Urinary Elimination
Today you are working on a medical-surgical unit. Each of your four clients has an indwelling urinary catheter and is resting in bed. You will now receive report on each client.
Which of the following clients should you manage first?
a. The client who is 1 day postoperative and needs their indwelling catheter removed
b. The client with a condom catheter who reports pain each time he urinates
c. The client with dementia who pulled off his condom catheter
d. The client with an indwelling urinary catheter who has green exudate seeping from the urethra
The client with dementia who pulled off his condom catheter
This is the client you should see first. When a condom catheter is removed traumatically, tissue damage can result. Also, a condom catheter can impair circulation to the penis if it is applied incorrectly, and that might be why the client removed it. Since the client has dementia and might not be able to answer your questions reliably, your immediate nursing assessment is imperative. When deciding which client to see first, you can use the nursing process as a guide. It is usually best to see clients who require a nursing assessment before clients who need routine interventions. Base your assessment priorities on immediate potential or actual immediate threats to airway, breathing, and circulation. Or, use Maslow’s hierarchy to plan care by meeting physiological and safety needs prior to higher-level needs.
a. The client who is 1 day postoperative and needs their indwelling catheter removed - Although this client might be eager to have their catheter removed, it is not the highest priority among these four clinical scenarios
b. The client with a condom catheter who reports pain each time he urinates - Dysuria, or painful urination, is most likely due to infection or presence of renal calculi (stones). You’ll have to collect a urine specimen to help determine the cause, but this is not the highest priority among these four clinical scenarios
ATI Skills - Urinary Elimination
Now that you have determined that you must see the client who pulled off his condom catheter first, you enter his room. You note that the skin barrier around the catheter had become loose, resulting in the catheter sliding off without any tissue damage when the client removed the catheter.
Before replacing the condom catheter, which of the following nursing actions should you perform?
a. Cleanse the glans penis with povidone-iodine.
b. Apply bacitracin ointment to the meatus.
c. Provide perineal care with soap and water.
Provide perineal care with soap and water
ATI Skills - Urinary Elimination
Which of the following clients will you see next?
a. The client who is 1 day postoperative and needs their indwelling urinary catheter removed this morning.
b. The client with a condom catheter who reports pain each time they urinate.
c. The client with an indwelling catheter who has green exudate seeping from their urethra.
The client with a condom catheter who reports pain each time they urinate
ATI Skills - Urinary Elimination
You call the client’s provider, who asks you to obtain a clean-catch specimen for urinalysis and urine culture. You collect the specimen and send it to the laboratory for analysis. You are ready to see another client. Which client will you see next?
Which of the following clients will you see next?
a. The client who is 1 day postoperative and needs their indwelling urinary catheter removed this morning.
b. The client with an indwelling urinary catheter who has green exudate seeping from their urethra.
The client with an indwelling urinary catheter who has green exudate seeping from their urethra
ATI Skills - Wound Care
How can I help reduce the pain associated with wound dressings?
- Selecting the correct type of dressing can help
- In general, keeping some moisture within a wound reduces pain
- Choose dressings that have enough adhesive to stay in place but will not be too difficult to remove
- Absorptive dressings can help decrease excessive moisture, which can otherwise lead to maceration and additional pain
- Packing wounds too tightly or wrapping a bandage too tightly can also increase pain
- Change dressings infrequently (unless otherwise prescribed) to reduce pain
- When a client is still experiencing considerable pain with dressing changes, consider offering premedication and providing a relaxing environment prior to dressing changes
- Complete pain assessment prior to dressing changes to help plan alternative methods of delivering wound care
ATI Skills - Wound Care
A client has a chronic wound and poor nutritional status. What fluids other than water can be offered to help increase hydration status?
One important component of fluid hydration is increasing the number of times you offer clients fluids (not just with meals)
Alternatives to water are:
* popsicles
* flavored gelatin
* soup
* sorbet
* ice cream
* milk
* ice chips
ATI Skills - Urinary Elimination
A client has a chronic wound and poor nutritional status.
HOW CAN DEHYDRATION MAKE THE CLIENT’S WOUND WORSE?
ALWAYS CONTINUE TO ASSESS HYDRATION STATUS WHEN CARING FOR CLIENTS WHO HAVE WOUNDS
**DEHYDRATION CAN LEAD TO: **
* WEIGHT LOSS
* DRY SKIN
* RAPID PULSE
* HYPOVOLEMIA
* LOW-GRADE FEVER
* ORTHOSTATIC BP ALTERATIONS [LOW] - CAUSES POOR PERFUSION TO THE WOUND
Hypovolemia can impair tissue oxygenation and can therefore hinder wound healing. By keeping the client adequately hydrated, you can also decrease risk for pressure injury formation.
ATI Skills - Wound Care
How should I assess a new wound?
- Include the wound’s location, age, size, stage or depth, presence of tunneling or undermining, manifestations that impair healing (necrosis, erythema), manifestations that aid in healing (wound edges, granulation), exudate characteristics, pain, and temperature
- Assess size using a ruler or other device to measure the exact dimensions of the wound, including its depth
- Describe the wound’s age in days, weeks, or months
- Location should reflect anatomic references
- Document the amount, color, and odor of any exudate
- Every additional component you report when assessing a wound can help contribute to the correct diagnosis, treatment, management, and — ultimately — healing of the wound
ATI Skills - Wound Care
Different types of necrotic tissue and how to distinguish them apart:
ESCHAR
Color: Black / Brown
Moisture content: Can be hard OR soft/soggy
Adherence: Firmly attached to wound
% of wound involved: 50-100%
WOUND PRESENCE: “FULL-THICKNESS”
STAGE 3
STAGE 4
UNSTAGEABLE
ATI Skills - Wound Care
Different types of necrotic tissue and how to distinguish them apart:
SLOUGH
Color: Yellow / White / Milkyish
Moisture content: Soft, Soggy, Stringy
Adherence: Firmly attached OR in clumps
% of wound involved: 25-100%
WOUND PRESENCE: “FULL-THICKNESS”
Stage 3
Stage 4
Unstageable
ATI Skills - Wound Care
TYPES OF EXUDATE:
SEROUS
CLEAR & THIN
Composed of PLASMA
Yellow-ish or pale pink-ish tint due to presence of RBC
NORMAL FINDING FOR WOUND HEALING PROCESS
Released from damaged / inflammed tissue
ATI Skills - Wound Care
TYPES OF EXUDATE:
PURULENT
THICK & OPAQUE
Composed of WBC/NEUTROPHILS
Yellow/Green/Tan
INDICATION OF AN INFECTION
Produced in response to infection and/or inflammation
ATI Skills: Wound Care
TYPES OF EXUDATE:
SANGUINEOUS
THIN
Composed of RBC
BRIGHT RED
NORMAL FINDING FOR WOUND HEALING PROCESS AS LONG AS IT IS NOT PROLONGED/EXCESSIVE
ATI Skills: Wound Care
TYPES OF EXUDATE:
SEROSANGUINEOUS
Thin
Composed of SEROUS + SANGUINEOUS Fluid
Light red / Pink-ish
NORMAL PART OF EARLY WOUND HEALING PROCESS
ATI Skills: Wound Care
After receiving report from the postanesthesia care nurse, you assess your client. After confirming that his vital signs remain within normal limits, you inspect his abdomen and his surgical dressing.
While assessing the client’s abdomen, you note that the Jackson-Pratt drain’s reservoir is expanded and half full of blood. Which is the appropriate action fro you to take at this time?
a. Empty the reservoir
b. Notify the surgeon about the blood loos
c. Remove the drain
Empty the reservior
The Jackson-Pratt drain incorporates a flexible bulb that aspirates drainage from the wound by self-suction. When the reservoir is half-full, the suction pressure is diminished. This it is appropriate to empty it and record the amount of drainage you discard
ATI Skills: Wound Care
You empty 60 mL of bright-red bloody drainage from the JP reservoir and record this on the client’s output record
To reactivate the Jackson-Pratt drain, you should do which of the following?
a. Attach the device to a wall suction unit and set to low suction.
b. Collapse the drainage bulb fully and secure the seal.
c. Fully expand the bulb and allow it to drain by gravity
Collapse the drainage bulb fully and secure the seal
ATI Skills - Wound Care
At this time, you must secure the JP drainage device
To maintain your client’s safety and to prevent dislodgement of the drain, you secure the Jackson-Pratt drainage system to which of the following?
a. Client’s gown
b. Surgical dressing
c. Bed frame
Client’s gown
ATI Skills: Wound Care
An hour later, you return to reassess the client. He states that his pain is tolerable with the use of the pump and he is otherwise comfortable. His vital signs remain stable, and you help him use his incentive spirometer. Before you leave, you check the integrity of his surgical dressing.
When checking the dressing, you note that the Jackson-Pratt drain is intact and draining and that there is a quarter-sized area of fresh red bloody drainage noticeable on the dressing. Which of the following is the appropriate action for you to take at this time?
a. Mark the edges of the area of drainage with tape
b. Replace the dressing with a fresh sterile dressing.
c. Apply another dressing on top of the dressing.
Mark the edges of the area of drainage with tape
ensures rest of care team can see and monitor client for increasing drainage/signs of hemorrhage
ATI Skills: Wound Care
An hour later, you reassess your client. His vital signs remain stable and you remind him to use his incentive spirometer. Before you leave, you check the integrity of the surgical dressing. The area of drainage is unchanged; however, the Jackson-Pratt drainage reservoir is half-full. You remove 60 mL of pale, blood-tinged, watery yellow drainage from the Jackson-Pratt’s reservoir.
When documenting the wound drainage in the client’s medical record, you describe it as which of the following?
a. Serous
b. Purulent
c. Serosanguineous
SEROSANGUINEOUS
Serosanguineous drainage is plasma mixed with blood. It is thinner and more watery than blood, often yellowish in color, and blood-tinged, rather than bright red and bloody seen in sanguineous drainage
ATI Skills - Wound Care
After receiving report, you assess your client. After determining that her vital signs are within normal limits, you observe the client’s sacral area while repositioning her. You document the following: Intact skin over the sacral area with a well-defined area of redness 2 cm in width and 3 cm in length. When palpated, the area feels boggy and is nonblanching.
Which of the following is appropriate to add to your documentation of the client’s sacral area?
a. Client has a stage 1 pressure injury
b. Client has a stage 2 pressure injury
c. Client has partial-thickness skin loss
Client has a stage 1 pressure injury
A stage 1 pressure injury is an observable alteration seen in intact skin over an area of pressure as compared with the surrounding or adjacent skin. These changes may include alterations in skin color or temperature or tissue consistency or sensation. Your description of intact skin with a well-defined area of redness that is boggy and nonblanchable meets the criteria for a stage 1 pressure injury
Stage 2: A stage 2 pressure injury is a visible area of damage, which may look like an abrasion, a blister, or a shallow crater. The area is typically edematous and there may be drainage from the non-intact skin
This client’s skin is intact. There is no evidence of skin loss at this time.
ATI Skills - Wound Care
You notify the client’s provider that the client has a stage 1 pressure injury of the sacral area. Following your facility’s guidelines, you also notify the risk manager, who responds as follows.
Which of the following factors should you include in the list of risk factors on the poster? [Select all that apply]
a. Incontinence
b. Previous hx of pressure injuries healed by scar formation
c. Impaired cognitive ability
d. Serum prealbumin 19.6 mg/dL
e. Darkly pigmented skin
f. Braden score less than 16
a. Incontinence - Both fecal and urinary incontinence increase the risk for pressure injury formation. Skin exposed continually to moisture leads to maceration, and fecal bacteria can cause infection, irritation, and breakdown
b. Previous hx of pressure injuries healed by scar formation - Areas of skin that have previously had to heal by scar formation are typically not as strong and cannot tolerate pressure as well as areas of undamaged skin
c. Impaired cognitive ability - Clients who have cognitively impairment cannot always sense when they need to change position and often cannot change position independently. This also applies to clients who are heavily sedated
f. Braden score less than 16 - The Braden Scale determines pressure-injury risk via six subscales: sensory perception, moisture, activity, mobility, friction, and shear. Scores range from 6 to 23; the lower the score, the greater the risk for pressure injury formation. For adults, a score less than 18 indicates increased risk
A prealbumin level of less than 19.5 mg/dL would indicate inadequate nutrition, which is a potential risk factor for pressure injury development. While serum protein levels are influenced by other factors, a level of 19.6 mg/dL in itself does not indicate pressure injury risk due to malnutrition
Sometimes, darkly pigmented skin requires a different assessment technique for pressure injury formation. However, it is not a risk factor for skin breakdown
ATI Skills - Wound Care
When completed, your poster will list the following risk factors for pressure injury formation: paralysis, immobilization, sensory loss, chronic circulatory impairment, fever, anemia, malnutrition, dehydration, incontinence, advanced age, sedation, edema, and history of pressure injuries. Meanwhile, you update your client’s nursing care plan to include interventions aimed at promoting healing of her skin
Which of the following nursing actions should you include in the client’s plan of care?
a. Apply a moisture-barrier cream to the sacral area.
b. Massage the skin over the bony prominences.
c. Keep the head of the client’s bed elevated at least 45 degrees
Apply a moisture-barrier cream to the sacral area
ATI Skills - Wound Care
Your updated care plan also includes maintaining the client’s turning schedule and closely monitoring her nutrition and hydration. After reviewing the updated plan, the risk manager has another question for you.
Which of the following dressings is the best choice of a wound dressing for this client?
a. Hydrogel
b. Wet-to-dry
c. Transparent
Transparent - able to easily see / assess wound
ATI Skills - Wound Care
You explain the rationale for your choice of the transparent dressing to the risk manager. After listening, the risk manager has a final question for you:
Which of the following is a disadvantage of a hydrocolloid dressing?
a. It must be changed several times per day
b. It does not allow visualization of the wound
c. It must be secured with the use of tape
It does not allow visualization of the wound
ATI Skills - Wound Care
You are assigned to care for a client who was readmitted to the hospital following a colon resection with wound dehiscence. Reviewing the client’s plan of care, you note a prescription for irrigating the wound every 8 hours with 0.9% sodium chloride. After receiving report from the nurse who cared for the client on the previous shift, you assess your client. You measure his vital signs and confirm that they are within normal limits. The client reports a pain level of 4 on a 0-to-10 scale. When you tell him that you will be back soon to perform the wound irrigation, the client questions your plan. You explain to the client the purpose of the irrigations and premedicate him with the prescribed analgesic prior to the irrigation. You tell him you will return in a half hour to reassess his pain level and perform the irrigation.
After closing the curtain around the client’s bed, you lift his gown to expose the horizontal abdominal wound and assist the client into a comfortable position for the irrigation. Which of the following positions is appropriate for the wound irrigation?
a. Side-lying
b. High-Fowler’s
c. Supine
Side-lying
ATI Skills - Wound Care
You position the client comfortably on his side and remove the old dressing using the appropriate technique. You note that the horizontal wound has an opening approximately 10 cm long and 5 cm across at the widest point. The wound base is red in color, moist, and has a rough (not smooth) surface.
When charting the description of the wound, you should document the presence of which of the following?
a. Exudate
b. Granulation
c. Slough
Granulation
Granulation tissue - INDICATES HEALTHY, HEALING WOUND
ATI Skills - Wound Care
Now that you have assessed the wound and properly positioned the client, you perform the irrigation using a slow continuous flush of warmed 0.9% sodium chloride. You monitor the client for the duration of the irrigation for increased pain and observe the solution that returns in the basin for clarity and for any debris. You notice that the solution begins to have a slightly pink color and observe that the wound base is bleeding.
Which of the following actions is appropriate for you to take at this time?
a. Apply pressure to the bleeding area of the wound
b. Change to a pulsatile flush until the returns are clear
c. Reduce the force you are using to flush the wound
Reduce the force you are using to flush the wound
ATI Skills - Wound Care
You continue the irrigation with less pressure. The returns change from slightly pink to clear. When you complete the irrigation, you apply a new dressing to the wound as prescribed using surgical asepsis. You reposition the client for comfort. You document the procedure in the client’s medical record and notify the provider of your findings. The provider assesses the wound and prescribes a wound vacuum-assisted closure (VAC). You explain the procedure to the client and obtain the supplies. When you return to the client’s room with the supplies, the client has another question for you.
In answering the client, you explain the nursing action that help maintain an airtight seal for the wound VAC device or the negative pressure wound therapy (NPWT). Which of the following information should you include? (Select all that apply.)
a. Clip the hair along the wound borders.
b. Cut the transparent film to extend 1 to 2 cm beyond the wound borders.
c. Use strips of transparent film to patch any leaks.
d. Use adhesive remover to help remove the transparent dressing.
e. Avoid wrinkling the transparent film while applying it to the foam
a. Clip the hair along the wound borders
c. Use strips of transparent film to patch any leaks.
d. Use adhesive remover to help remove the transparent dressing.
e. Avoid wrinkling the transparent film while applying it to the foam
ATI Skills - Wound Care
After applying the wound VAC device and initiating the therapy, you document your interventions in the client’s medical record. You also update the client’s care plan to reflect the nursing care required for a client receiving wound VAC therapy.
Which of the following assessment findings in a client who has a wound VAC would alert you to a potential wound infection?
a. Increased redness of the base of the wound
b. Increased pain after applying the wound VAC dressing
c. Increased exudate in the drainage chamber
Increased exudate in the drainage chamber
ATI Skills - Ostomy Care
You are working on a medical-surgical unit. One of your clients is a 30-year-old woman transferred from the post anesthesia care unit after ileostomy surgery for Crohn’s disease. You perform a postoperative assessment and find the client alert, oriented, and responding appropriately. However, when you pull down the sheet to observe her abdomen, you observe a serious clinical manifestation. Her ileostomy pouch contains a significant amount of bright-red blood.
Which of the following types of output is FIRST expected from an ileostomy postoperatively?
a. Loose, liquid stools after 1-2 days
b. Serous drainage after 6-8 hours
c. Formed to semi-formed stool within 2-5 days
d. Pasty yellow-brown stool within 3-4 days
Loose, liquid stools after 1-2 days
ATI Skills - Ostomy Care
You have determined that you must assess the client’s abdomen first. You observe, auscultate, and palpate it. You find the abdomen is slightly firm, but not distended. The abdominal incision, closed with staples, is clean, dry, and intact. Bowel sounds are hypoactive in all four quadrants.
What should you assess next?
a. Urine output
b. Suture line
c. Stoma
Suture line
After checking for signs of abdominal bleeding, assess the suture line — also called the mucocutaneous junction - for signs of frank bleeding due to injury of the mesenteric artery. The presence of frank bleeding is a medical emergency requiring the surgeon’s immediate intervention.
ATI Skills - Ostomy Care
You assess the suture line carefully, but you do not see any bleeding, and it is intact and dry all around the edges.
Which of the following assessments should be your next step?
a. Urine Output
b. Stoma
Stoma
**ASSESS STOMA FOR BLEEDING - trauma to the stoma mucosa can also cause bleeding
**
ATI Skills - Ostomy Care
On postoperative day 2, the client’s abdomen is soft with no signs of distention. You auscultate bowel tones in all four quadrants, and you note an increased amount of watery green effluent with gas in the ostomy pouch. The surgeon writes an order to start the client on a liquid diet for 24 hours and advance it as tolerated. Preparing the client to resume eating, you review the dietary recommendations with her.
Which of the following foods should the client avoid to prevent blockage?
a. Noodles and white bread
b. Cream cheese and bananas
c. Fresh tomatoes and celery
d. Lean meats and poultry
Fresh tomatoes and celery
High-fiber foods, such as fresh tomatoes and celery, may cause food blockage.
Other high-fiber foods to avoid are mushrooms, coconut, popcorn, and some shellfish, such as shrimp and lobster.
ATI Skills - Ostomy Care
On post-op day #4, the client reports a loss of appetite, drowsiness, and leg cramps. The output from the ostomy is 1,200 mL in past 24 hrs.
Which of the following is a likely cause of this electrolyte abnormaltity?
a. Bleeding
b. High-volume effluent
c. Dehydration
d. Renal failure
High-volume effluent
ATI Skills - Ostomy Care
After the electrolyte imbalance is corrected and the client is consistently stable, the surgeon writes a discharge order. The client has demonstrated ileostomy self-care; however, she tells you that she is concerned about being with other people because of the odor. You ask her to recall the information you reviewed with her earlier about odor management.
Which of the following statements indicates that the client understands the strategies that can be used to avoid odorous gas?
a. “A well-fitted pouching system with a filter helps prevent odor.”
b. “My friend suggested placing an aspirin tablet inside the ostomy pouch.”
c. “I’ll eat lots of cheese and eggs to minimize the odor.”
d. “I’ll just avoid social situations for an hour or so after I eat gassy foods.”
“A well-fitted pouching system with a filter helps prevent odor.”
ATI Skills - Ostomy Care
You are working on a medical-surgical unit. You are assigned to care for a 56-year-old client who is 3 days postoperative following the emergent creation of a temporary transverse loop colostomy. The client has made satisfactory progress in pain control and diet advancement. Even though the ostomy is intended to be temporary, the client has expressed that they feel both grieved and angry whenever they think of what life will be like with an ostomy. The client’s partner is at the bedside and plans to help the client at home after discharge. Your client’s stoma is red and moist, and the pouch contains a small amount of liquid stool.
Which of the following psychosocial assessment findings indicates a normal response to the alteration in body function the client had just undergone?
a. Anxiety and refusal to eat
b. Severe depression, sometimes with suicidal ideation
c. Confidence that life will be back to normal upon discharge home
d. Anger and feelings of loss
Anger and feelings of loss
ATI Skills - Ostomy Care
Hoping to be d/c home ASAP, your client reluctantly asks you to teach them how to take care of their new colostomy.
Which of the following is the best way to help the client regain a sense of control and improve their self-esteem?
a. Distract the client with a book or movie while you provide ostomy care during the hospital stay.
b. Request client participate in their ostomy care as they are physically able.
c. Encourage the client to deny their fears, leaving them behind as they move forward with their new life.
d. Reassure the client that they do not need to touch the stoma but encourage the client to look at it.
Request client participate in their ostomy care as they are physically able
ATI Skills - Ostomy Care
You follow your discussion of pouching systems with a short explanation of the difference between pre-cut and custom-cut skin barriers, as well as disposable and reusable pouches. After you answer your client’s questions regarding ostomy appliances, you proceed to talk with them about taking care of the skin around the stoma.
Which of the following information about peristomal skin care would be correct to tell the client?
a. Colostomy clients have a higher incidence of skin problems than ileostomy clients.
b. The peristomal skin may be slightly red and excoriated.
c. The pouch should be frequently checked for signs of leakage.
d. The most common cause of peristomal skin disorders is chronic illness.
The pouch should be frequently checked for signs of leakage
ATI Skills - Ostomy Care
The client has now successfully changed the pouch with your help and that of their partner, taking care not to dislodge the external rod used to support their loop colostomy. However, the client would like to be able to do it on their own since after discharge, their partner will be at work during the day. The client asks to further review some pouch change information
with you.
Which of the following statements indicate that the client has a good understanding of how to place a new appliance?
a. “I should measure the stoma, then cut the appropriate size before removing the adhesive backing. My stoma will shrink over the next several weeks, so I’ll need to measure it regularly.”
b. “I should scrub my skin with warm water and dry it completely before applying the new pouching system. It’s important for the skin to be dry before application.”
c. “After applying the skin barrier, I should use some adhesive remover to c be sure any residue is completely gone so that the pouch will adhere properly to the skin barrier. Adherence is important to prevent leakage.”
d. “After I place the skin barrier, I should maintain gentle finger pressure around it for a few seconds. Then I can make a pinhole the pouch to prevent gas accumulation before snapping it onto the barrier.”
“I should measure the stoma, then cut the appropriate size before removing the adhesive backing. My stoma will shrink over the next several weeks, so I’ll need to measure it regularly.”
ATI Skills - Ostomy Care
After 7 days in the hospital, the client has made excellent progress toward independence with their ostomy care, and the surgeon has removed the supporting device from their loop colostomy. You have already educated them in several areas of ostomy care, but there are
a few other items to discuss before the client is discharged.
Which should also be included in the client’s education?
a. Colostomy irrigation
b. An intermittent catheterization schedule
c. Resumption of normal activities, includng travel and sex
Resumption of normal activities, includng travel and sex
ATI Skills - Ostomy Care
You are working on a medical-surgical unit. You are assigned to care for a 62-year-old client admitted to your unit 5 days ago after the creation of a sigmoid colostomy due to rectal cancer. The client has type 1 diabetes mellitus, osteoarthritis, and cardiovascular disease. They are now beginning to manage their ostomy pouch changes. As you enter the room for a routine assessment, the client tells you they have developed some pain and burning at the stoma site. You note that the skin around the stoma appears erythematous, but the client denies any contact of the skin with fecal matter or mucus. You decide to remove the pouch to assess the stoma more closely only to find a 5 mm mucocutaneous separation.
Which of the following actions should you take first?
a. Flush the area with normal saline solution.
b. Fill in the open space with skin barrier paste.
c. Probe the area to determine the depth of separation.
d. Inspect the circumference of the stoma.
Inspect the circumference of the stoma
ATI Skills - Ostomy Care
After the surgeon and enterostomal therapist leave the room, the client asks, “Why did the doctor say that I am at risk for this complication?” You should explain that the risk of suture-line separation increases with which of the following factors?
a. Lower abdominal location
b. Antiplatelet medication
c. Cardiovascular disease
d. Diabetes mellitus
Diabetes mellitus
ATI Skills - Ostomy Care
After explaining the risk factors, you give the client information about caring for the area of separation, along with a follow-up appointment with the wound, ostomy and continence nurse.
When the client asks you about any other complications that could result from the separation, which of the following should you explain?
a. Folliculitis
b. Stagnated healing
c. Prolapse
d. Peristomal hernia
Stagnated healing
ATI Chapter - Nutrition
A nurse is preparing a presentation about basic nutrients for a group of high school athletes. The nurse should include that which of the following provides the body with the most energy?
a. Fat
b. Protein
c. Glycogen
d. Carbohydrates
Carbohydrates
ATI Chapter - Nutrition
A nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include? [Select all that apply]
a. Older adults are more prone to dehydration than younger adults
b. The recommended intake of daily fiber decreases in older adults
c. Many older adults need calcium supplements
d. Older adults need more calories than they did when they were younger
e. Older adults should consume a diet low in carbohydrates
a. Older adults are more prone to dehydration than younger adults - When taking action, the nurse should include that sensations of thirst diminish with age, leaving older adults more prone to dehydration
b. The recommended intake of daily fiber decreases in older adults - The recommended amount of daily fiber intake decreases in the older adult due to their lower caloric intake
c. Many older adults need calcium supplements - Many older adults need an increased intake of calcium, whether through their diet or through calcium supplements to help prevent bone demineralization (osteoporosis)
d. Older adults have a slower metabolic rate, so they require less energy (unless they are very active) and, therefore, need fewer calories
e. Older adults should consume a healthy diet with an appropriate intake of calories through a balanced diet while limiting intake of fat, salt, refined sugars, and alcohol
ATI Chapter - Nutrition
A nurse is caring for a client who is at high risk for aspiration. Which of the following actions should the nurse take?
a. Giving the client thin liquids
b. Instructing the client to tuck their chin when swallowing
c. Having the client use a straw → Using a straw increases the client’s risk for aspiration.
d. Encouraging the client to lie down and rest after meals
Instructing the client to tuck their chin when swallowing
ATI Chapter - Bowel Elimination
A nurse is teaching a client about performing a fecal occult blood test at home. Which of the following information should the nurse include?
a. Do not eat red meat within one day of the test
b. One stool specimen is sufficient for testing
c. A red color indicates a positive test
d. Ensure the specimen does not include urine
Ensure the specimen does not include urine
ATI Chapter - Bowel Elimination
A nurse is prepping to administer a cleansing enema to a client. Place the steps the nurse should plan to take in the correct order:
Slowly insert the rectal tube into the client’s rectum
Warm the enema solution
Ask the client to retain the solution
Lubricate the end of the rectal tube
Hang the enema container 30-45 cm (12-18 in) above client’s anus
- Warm the enema solution
- Lubricate the end of the rectal tube
- Slowly insert the rectal tube into the client’s rectum
- Hang the enema container 30-45 cm (12-18 in) above client’s anus
- Ask the client to retain the solution
ATI Chapter - Bowel Elimination
A nurse is assessing a client who has had diarrhea for 3 days. Which of the following findings should the nurse expect? [Select all that apply]
a.Bradycardia
b. Hypotension
c. Elevated temperature
d. Peripheral edema
e. Poor skin turgor
Hypotension
Elevated temperature
Poor skin turgor
ASSESS FOR SIGNS OF DEHYDRATION SECONDARY TO DIARRHEA
Patient will present as: Tachycardic (fast heart rate) Elevated BP (not hypotension)
ATI Chapter - Bowel Elimination
A nurse is teaching a client who has diarrhea. Which instructions should the nurse include? [Select all that apply]
a. Eat raw fruit with the skin
b. Eat yogurt when diarrhea has stopped
c. Increase fluid intake
d. Drink hot fluids
e. Avoid caffeinated beverages
b. Eat yogurt when diarrhea has stopped
c. Increase fluid intake
e. Avoid caffeinated beverages
ATI Chapter - Urinary Elimination
A nurse is teaching a client who has recurrent UTIs. Which of the following instructions should the nurse include [Select all that apply]
a. Urinate after sexual intercourse
b. Drink at least 1 L fluid / day
c. Clean perineum from front → back
d. Wear nylon undergarments
e. Avoid bubble baths
a. Urinate after sexual intercourse
c. Clean perineum from FRONT to BACK
e. Avoid bubble baths
ATI Chapter - Urinary Elimination
A nurse is teaching a new nurse about urine specimen collection. Match the following tests to the procedures:
RANDOM URINALYSIS
a. Obtain a non-sterile urine specimen
b. Clean the urethral meatus prior to obtaining the urine specimen
c. Collect urine for a 24 hr period
d. Obtain a sterile urine specimen from an indwelling urinary catheter
Random urinalysis - Obtain a non-sterile urine specimen
ATI Chapter - Urinary Elimination
A nurse is teaching a new nurse about urine specimen collection. Match the following tests to the procedures:
CLEAN-CATCH / MIDSTREAM FOR CULTURE & SENSITIVITY
a. Obtain a non-sterile urine specimen
b. Clean the urethral meatus prior to obtaining the urine specimen
c. Collect urine for a 24 hr period
d. Obtain a sterile urine specimen from an indwelling urinary catheter
Clean - catch midstream for culture and sensitivity (C & S) - Clean the urethral meatus prior to obtaining the urine specimen
ATI Chapter - Urinary Elimination
A nurse is teaching a new nurse about urine specimen collection. Match the following tests to the procedures:
TIMED URINE SPECIMEN
a. Obtain a non-sterile urine specimen
b. Clean the urethral meatus prior to obtaining the urine specimen
c. Collect urine for a 24 hr period
d. Obtain a sterile urine specimen from an indwelling urinary catheter
Timed urine specimen - Collect urine for a 24 hr period
ATI Chapter - Urinary Elimination
A nurse is teaching a new nurse about urine specimen collection. Match the following tests to the procedures:
CATHETER URINE SPECIMEN FOR C+S
a. Obtain a non-sterile urine specimen
b. Clean the urethral meatus prior to obtaining the urine specimen
c. Collect urine for a 24 hr period
d. Obtain a sterile urine specimen from an indwelling urinary catheter
Catheter urine specimen for C&S - Obtain a sterile urine specimen from an indwelling urinary catheter
ATI Chapter - Urinary Elimination
A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take? [Select all that apply]
a. Empty the client’s urinary drainage bag when it is ¾ full
b. Keep the urinary drainage bag below the level of the client’s bladder
c. Assess the client’s need for the indwelling urinary catheter daily
d. Rest the urinary collection bag on the floor when the client is sitting in the chair
e. Maintain a closed system of the client’s urinary catheter
b. Keep the urinary drainage bag below the level of the client’s bladder
c. Assess the client’s need for the indwelling urinary catheter daily
e. Maintain a closed system of the client’s urinary catheter
ATI Chapter - Urinary Elimination
A nurse is teaching a client who reports stress urinary incontinence. What instructions should the nurse include? [Select all that apply]
a. Maintain adequate fluid intake
b. Empty bladder completely with each void
c. Avoid bladder irritants [caffeine + alcohol]
d. Perform pelvic muscle exercises 3-4 x day
a. Maintain adequate fluid intake
b. Empty bladder completely with each void
c. Avoid bladder irritants [caffeine + alcohol]
d. Perform pelvic muscle exercises 3-4 x day
ALL OF THE ABOVE!!!
ATI Chapter - Urinary Elimination
A nurse is preparing to initiate a bladder-retraining program for a client who has urge incontinence. Which actions should the nurse take? [Select all that apply]
a. Restrict client’s intake of fluids during the daytime
b. Have the client record urination times
c. Gradually increase the time of the client’s urination intervals
d. Remind client to try to hold urine until the next scheduled urination time
e. Restrict coffee intake to 2 servings each day
b. Have the client record urination times
c. Gradually increase the time of the client’s urination intervals
d. Remind client to try to hold urine until the next scheduled urination time
ATI Chapter - Wound Care
A nurse is reviewing the wound healing process with a group of newly licensed nurses. The nurse should include in the information which of the following alterations for wound healing by secondary intention? [Select all that apply]
a. Stage 3 pressure injury
b. Sutured surgical incision
c. Casted bone fx
d. Laceration sealed with adhesive
e. Open burn area
a. Stage 3 pressure injury
e. Open burn area
OPEN PRESSURE INJURIES HEAL BY SECONDARY INTENTION = Process for wounds that have tissue loss and widely separated edges
b. Sutured sx incision - primary = process for wounds that have little to no tissue loss / well-approximated edges
c. Casted bone fx - injury to underlying structure and does not require healing of skin
d. Laceration sealed w/ adhesive - primary
ATI Chapter - Wound Care
A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in their surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following actions should the nurse take? [Select all that apply]
a. Cover the area with saline-soaked sterile dressings
b. Apply an abdominal binder snuggly around the abdomen
c. Use sterile gauze to gently apply pressure to the exposed tissues
d. Position the client supine with hips and knees bent
e. Offer client a warm beverage [herbal tea]
a. Cover the area with saline-soaked sterile dressings
**cover the wound with a sterile dressing soaked with sterile normal saline solution to keep the exposed organs and tissues moist until the surgeon can assess and intervene
**
d. Position the client supine with hips and knees bent
**this position minimizes pressure on the abdominal area
**
b. Apply an abdominal binder snugly around the abdomen [abdominal binder can help PREVENT..not treat…a wound evisceration]
c. Use sterile gauze to apply gentle pressure to the exposed tissues [avoid handling or applying pressure to ANY exposed organs/tissue → these actions increase the risk of trauma / perforation]
e. Offer client a warm beverage [herbal tea] [client should be NPO in anticipation for sx]
ATI Chapter - Wound Care
A nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? [Select all that apply]
a. Increase in incisional pain
b. Fever and chills
c. Reddened wound edges
d. Increase in serosanguineous drainage
e. Decrease in thirst
a. Increase in incisional pain
b. Fever and chills
c. Reddened wound edges
d. Increase in serosanguineous drainage - nurse should expect the client to have purulent drainage with an incisional infection
ATI Chapter - Wound Care
A nurse is caring for a 45-year-old client who is 2 days postoperative following an appendectomy and has type I diabetes mellitus. Their Hgb is 12 g/dL and BMI is 17.1. The incision is approximated and free of redness, with scant serous drainage on the dressing. The nurse should recognize that the client has which of the following risk factors for impaired wound healing? [Select all that apply]
a. Age
b. Chronic illness
c. Low hemoglobin
d. Malnutrition
e. Poor wound care
b. Chronic illness
DM = chronic illness that places additional stress on body’s healing mechanisms
c. Low hemoglobin
Hgb is ESSENTIAL for oxygen delivery to healing tissues
d. Malnutrition
underweight = malnourished = deficiences in essential nutrients delay wound healing
a. Age - age itself does not place them at an increased risk for impaired wound healing
e. Poor wound care - no indications there have been any breaches in aseptic technique during wound care
ATI Chapter - Wound Care
A nurse is caring for a client who is at risk for developing pressure injury. Which of the following interventions should the nurse use to help maintain the integrity of the client’s skin? [Select all that apply]
a. Keep HOB elevated at 30 degrees
b. Massage bony prominences frequently
c. Apply cornstarch liberally to skin after bathing
d. Have client sit on a gel cushion when in a chair
e. Reposition client every 3 hrs while in bed
a. Keep HOB elevated at 30 degrees
slightly elevating the HOB helps to reduce shearing forces that could tear sensitive skin on the sacrum, buttocks, and heels
d. Have client sit on a gel cushion when in a chair
sitting on gel, air, or a foam cushion redistributes weight away from ischial areas
cornstarch and powder can abrade the sensitive skin
ATI - Nutrition
Which action should a nurse take to assess a client who had a stroke for complications secondary to inadequate swallowing?
a. Auscultate the lungs
b. Place the tip of a tongue depressor on the client’s posterior tongue
c. Inspect the client’s uvula and soft palate with a penlight
d. Place fingers on the client’s throat and the level of the larynx and ask the client to swallow
a. Auscultate the lungs
ATI - Nutrition
A nurse is caring for a client who has impaired swallowing due to a CV accident. Which intervention should the nurse use to assist the client with feeding?
a. Provide them with a straw
b. Offer them thin fluids
c. Elevate the head of the bed 45 to 90 degrees
d. Place food on the weaker side of the mouth
c. Elevate the head of the bed 45 to 90 degrees
ATI - Nutrition
A charge nurse is reviewing anthropometric values with a new nurse. Which statement by the new nurse indicates an understanding of the teaching?
a. Isolated measurements of height and weight are of greater significance than changes over time
b. A weight increase of 4 pounds in a client who has renal failure indicates retention of 1,000 milliliters of fluid
c. The client should be weighed on the same scale at the same time each day
d. The ratio or height-to-wrist circumference is the most accurate way to identify obesity
c. The client should be weighed on the same scale at the same time each day
ATI - Nutrition
A nurse is caring for a client who has sustained a head injury and whose LOC fluctuates. The provider prescribes a full liquid diet, progressing to a pureed diet as tolerated. Before initiating feedings, it is essential that this client undergo which of the following?
a. Chest x-ray
b. Swallowing examination
c. Nasogastric tube insertion
d. Olfactory nerve evaluation
b. Swallowing examination
ATI - Nutrition
Which intervention should a nurse use at mealtimes for a client who has a visual impairment?
a. Identify the food location as though the plate were a clock
b. Direct the order in which food items are consumed
c. Have the client tilt their head forward while eating
d. Avoid talking to the client during mealtime
a. Identify the food location as though the plate were a clock
ATI - Nutrition
A nurse is reviewing a client’s lab values. Which information regarding albumin levels and nutritional status is correct?
a. Albumin level is a poor short-term indicator of protein status
b. Hydration status does not affect a client’s albumin level
c. An albumin level of 3.2 g/dL is within the expected reference range
d. Albumin level is calculated by keeping a 24-hour record of protein intake
a. Albumin level is a poor short-term indicator of protein status
ATI - Nutrition
What is the primary purpose for asking a client to keep a 3 to 7-day food diary?
a. To allow them to rely on health professionals to identify problem areas
b. To determine changes in their appetite
c. To evaluate any significant changes in body weight
d. To assess the pattern of intake and compare it with daily reference intakes
d. To assess the pattern of intake and compare it with daily reference intakes
ATI - Nutrition
Which of the following food choices are appropriate for a client who is prescribed a full-liquid diet? [Select all that apply]
a. Plain yogurt
b. Custard
c. Ice cream
d. Mashed potatoes
e. Pureed meat
f. Gelatin
a. Plain yogurt
b. Custard
c. Ice cream
f. Gelatin
ATI - NG Tube
A nurse teaches a group of unit nurses about clients needing gastric decompression. The nurse should identify which client needs NG tube intubation for gastric decompression?
a. A 6-year-old child who ingested a toxic substance
b. A 60-year-old client who has a gastrointestinal hemorrhage
c. A 40-year-old client who has a postoperative bowel obstruction
d. A 20-year-old client who has malabsorption syndrome
c. A 40-year-old client who has a postoperative bowel obstruction
ATI - NG Tube
A nurse is checking the client’s NG tube placement. Which procedure should the nurse implement?
a. Instill 20 mL of air into the tube and listen for a whooshing sound
b. Aspirate stomach contents and check pH
c. Aspirate stomach contents and check their color
d. Auscultate lung sounds
b. Aspirate stomach contents and check pH
ATI - NG Tube
A nurse is caring for a client who has an NG tube connected to suction. Which finding indicates that the tube has become occluded?
a. Active bowel sounds
b. Passing flatus
c. Increase in gastric secretions
d. Increased abdominal distention
d. Increased abdominal distention
ATI - NG Tube
A nurse is caring for a client who has a newly inserted NG tube. Which action should the nurse use to verify the initial placement of the tube?
a. Obtain an x-ray
b. Auscultate injected air
c. Take a pH measurement of gastric aspirate
d. Identify the color of gastric contents
a. Obtain an x-ray
ATI - NG Tube
A nurse is caring for a client who is recovering from gastric surgery, is NPO, and has an NG tube connected to suction. Which action should the nurse take to prevent dry mucous membranes?
a. Allow the client to suck on ice chips
b. Provide frequent mouth care
c. Apply petroleum jelly to the client’s naris
d. Offer throat lozenges for the client to use
b. Provide frequent mouth care
ATI - NG Tube
A nurse is informed during shift report that a client has an NG tube connected to continuous suction. The nurse should identify that this client must have which type of tube?
a. Dobhoff tube
b. Sengstaken-Blakemore tube
c. Salem sump tube
d. Ewald tube
c. Salem sump tube
ATI - NG Tube
A nurse performs a nasogastric intubation on a client and has reached the tube’s predetermined length. Which action should the nurse take first?
a. Inspect the oropharynx with a penlight and a tongue blade
b. Obtain an x-ray examination of the chest and abdomen
c. Tape the tube securely in place with a tube holder device
d. Aspirate gastric contents
a. Inspect the oropharynx with a penlight and a tongue blade
ATI - Enteral Tube Feeding
A nurse is caring for a group of clients. The nurse should identify that which client requires an enteral tube feeding?
a. A client who has a paralytic ileus
b. A client who has recently experienced facial trauma
c. A client who has dysphagia
d. A client who has a decreased appetite
c. A client who has dysphagia
ATI - Enteral Tube Feeding
A nurse is providing teaching about risk for aspiration with a client who is receiving intermittent bolus NG feedings. Which finding should the nurse instruct the client to report?
a. A feeling of fullness
b. Persistent coughing
c. Discomfort in the naris
d. Postfeeding belching
b. Persistent coughing
ATI - Enteral Tube Feeding
A nurse is inserting a small-bore feeding tube. Before initiating the feeding, the nurse should take which action to verify placement?
a. Measure the pH of gastric aspirate
b. Auscultate the epigastric area while injecting air
c. Obtain an x-ray
d. Place the open end of the tube in a cup of water
c. Obtain an x-ray
ATI - Enteral Tube Feeding
A nurse is administering an enteral tube feeding to a client. Which action should the nurse take to prevent aspiration?
a. Flush the feeding tube with 30 mL of water
b. Add blue food coloring to the enteral formula
c. Ensure the formula is at room temperature
d. Place the client in a Fowler’s position
d. Place the client in a Fowler’s position
ATI - Enteral Tube Feeding
A nurse is preparing to administer a continuous enteral tube feeding to a client. The nurse should take which action to prevent a complication of the tube feeding?
a. Limit the time the formula hangs to 8 hr
b. Flush the tube every 8 hr
c. Deliver the formula at a brisk rate
d. Allow the feeding bag to empty before refilling it
a. Limit the time the formula hangs to 8 hr
ATI - Enteral Tube Feeding
To determine the length of a nasointestinal tube to insert, a nurse should measure the distance from the tip of the client’s nose to the earlobe and from the earlobe to the…
a. Umbilicus
b. Xiphoid process
c. Manubrium plus 10 - 20 cm more
d. Xiphoid process plus 20 - 30 cm more
d. Xiphoid process plus 20 - 30 cm more
ATI - Enteral Tube Feeding
A nurse is inserting an NG tube for a client and asks the client to flex their head toward their chest after the tube passes through the nasopharynx. This action facilitates proper insertion of the tube by achieving which of the following?
a. Closing off the glottis
b. Preventing curling of the tube in the mouth
c. Allowing the client to breathe through their mouth
d. Opening the lower esophageal sphincter
a. Closing off the glottis
ATI - Enteral Tube Feeding
A nurse is caring for a client who has a significant risk of aspiration and requires nutritional support for about 2 weeks because they are unable to consume adequate nutrients orally. Which type of feeding tubes should the nurse anticipate the provider to prescribe?
a. Nasogastic tube
b. Nasointestinal tube
c. Percutaneous endoscopic gastrostomy tube
d. Percutaneous endoscopic jejunostomy tube
b. Nasointestinal tube
ATI - Enteral Tube Feeding
A client who lives in a long-term care facility is receiving intermittent enteral feedings and is experiencing social isolation. Which intervention should the nurse recommend?
a. Encourage the client to go to the dining room at meals times to talk with other clients
b. Suggest that the client watch television while feedings are being administered
c. Remind the client that they can have visitors after feeding administration times
d. Ask the facility chaplain to speak with the client
a. Encourage the client to go to the dining room at meals times to talk with other clients
ATI - Bowel Elimination
While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which action should the nurse take?
a. Measure the client’s vital signs
b. Notify the PCP
c. Lower the enema fluid container
d. Stop the enema instillation
c. Lower the enema fluid container
ATI - Bowel Elimination
A nurse is preparing an adult client for an enema. The nurse should assist the client into which position?
a. Prone
b. Dorsal recumbent
c. Right lateral with both knees at chest
d. Left lateral with the right leg flexed
d. Left lateral with the right leg flexed
ATI - Bowel Elimination
A nurse is preparing to administer a cleansing enema to a client who has poor sphincter control. Which action should the nurse take?
a. Place the client in the dorsal recumbent position on a bedpan
b. Administer the enema while the client sits on the toilet
c. Administer an antidiarrheal medication 3 hr prior to the enema
d. Instill 200 mL of fluid over an hour at 15-min intervals
a. Place the client in the dorsal recumbent position on a bedpan
ATI - Urinary Elimination
A nurse is applying a condom catheter for a client who is uncircumcised.
Which of the following actions should the nurse take?
a. Stretch the sheath portion of the condom catheter along the length of the penis.
b. Secure the sheath portion with adhesive tape.
c. Leave a space between the penis and sheath portion tip.
d. Reposition the foreskin after application.
c. Leave a space between the penis and sheath portion tip.
[The nurse should leave a space of 2.5 to 5 cm (1 to 2 in) between the tip of the penis and the end of the catheter. This space helps prevent irritation of the tip of the penis and allows full drainage of urine.]
ATI - Urinary Elimination
A nurse is planning to obtain a urinary specimen from a client’s closed urinary system. Identify the correct sequence of steps that the nurse should take:
* Transport the specimen to the lab
* Withdraw 3-30 mL of urine
* Attach a syringe to the collection port of the indwelling catheter
* Transfer the urine to a sterile specimen container
* Wipe the port with an alcohol swab or agency specified antiseptic
- Wipe the port with an alcohol swab or agency specified antiseptic
- Attach a syringe to the collection port of the indwelling catheter
- Withdraw 3 - 30 mL of urine
- Transfer the urine to a sterile specimen container
- Transport the specimen to the lab
ATI - Urinary Elimination
A nurse is preparing to remove a client’s indwelling urinary catheter.
Which of the following actions should the nurse take?
a. Pull the catheter out as quickly as possible.
b. Deflate the balloon completely before removal.
c. Cut the inflation port to deflate the balloon.
d. Tell the client to expect to feel a tugging sensation on removal.
b. Deflate the balloon completely before removal
ATI - Urinary Elimination
A nurse is providing perineal care for a female client who has an indwelling urinary catheter. Which area should the nurse cleanse last?
a. Urethral meatus
b. Labira minora
c. Perineum
d. Anus
d. Anus
[The nurse should identify that the basic aseptic principle applicable to perineal care is to cleanse from the area that is least contaminated to the area that is the most contaminated. The anal area is typically contaminated with coliform bacteria and should therefore be cleansed last.]
ATI - Urinary Elimination
A nurse is preparing to insert an indwelling catheter for a client. Which action should the nurse instruct the client to perform during the insertion procedure?
a. Bear down
b. Take deep breaths
c. Sip water
d. Tighten the perineum
a. Bear down
[The nurse should instruct the client to bear down as if to void because this relaxes the external sphincter and aids in the insertion procedure.]
ATI - Urinary Elimination
A nurse is assessing a client’s indwelling urinary catheter drainage at the end of the shift and notes the output is considerably less than the fluid intake. Which of the following actions should the nurse take first?
a. Irrigate the catheter.
b. Assess for peripheral edema.
c. Palpate for bladder distention.
d. Check the catheter for kinks.
d. Check the catheter for kinks
**[The nurse should identify that output that is considerably less than intake is a sign that the catheter is blocked. Therefore, the first action the nurse should take is to check the tubing for kinks and ensure the client’s urine flow is not obstructed.]
**
ATI - Urinary Elimination
A nurse is caring for a group of newly admitted clients. For which of the following clients should the nurse expect to receive a prescription for urinary catheterization?
a. A client who has a persistent urinary tract infection.
b. A client who has urge incontinence.
c. A client who is in the ICU for a gastrointestinal bleed.
d. A client who has incontinence due to cognitive decline.
c. A client who is in the ICU for a gastrointestinal bleed
[The nurse should expect a prescription for urinary catheterization for this client because precise measurement of urinary output is crucial for managing fluid balance in clients who are critically ill.]
a. Urinary tract infection - Urinary tract infections are treated with antimicrobial agents, increased fluid intake, and pain management. Therefore, the nurse should not expect a prescription for urinary catheterization for a client who has a persistent urinary tract infection.
b. Urge Incontinence - Treatment options for urge incontinence typically include pelvic floor exercises, medications, and bladder retraining. Therefore, the nurse should not expect a prescription for urinary catheterization for a client who has urge incontinence.
d. Incontinence - Incontinence due to cognitive decline is a type of functional incontinence that is typically treated with scheduled toileting and absorbent adult briefs. Urinary catheterization might be necessary as a last resort for a client who has incontinence due to cognitive decline. However, as this client is newly admitted, the nurse should not expect a prescription for urinary catheterization.
ATI - Urinary Elimination
A nurse is preparing a male client for intermittent urethral catheterization. Which of the following actions should the nurse take?
a. Grasp the penis at its base.
b. Lift the penis perpendicular to the body.
c. Hold the penis parallel to the client’s body.
d. Lift the penis to a 45° angle to the client’s body.
b. Lift the penis perpendicular to the body
Lifting the penis to a position perpendicular to the body, or at a 90° angle, while applying light traction straightens the urethral canal to facilitate catheter insertion.
ATI - Wound Care
A nurse is planning care for a client who has multiple wounds. During the initial stage of wound healing, which of the following should the nurse include in the plan of care?
a. Leave nonbleeding wounds open to the air
b. Administer a corticosteroid medication
c. Initiate mechanical debridement
d. Apply oxygen at 2 L/min via nasal cannula
d. Apply oxygen at 2 L/min via nasal cannula
Following an acute injury, the body responds best by increasing oxygen to improve perfusion, which is essential for healing. It is common to see a delay in the resolution of the inflammatory phase of chronic wounds in clients who have a lack of oxygen or poor perfusion
ATI - Wound Care
A nurse is staging a pressure injury over a client’s right heel area. The pressure injury has no eschar or slough and no exposed muscle or bone. The nurse should identify that this pressure injury is classified as which of the following?
a. Unstageable
b. A suspected deep tissue injury
c. Stage 4
d. Stage 3
d. Stage 3
The nurse should identify that this client has a stage 3 pressure injury indicated by full-thickness tissue loss appearing as a deep crater, without exposed muscle or bone. Stage 3 pressures can have slough, but it is not necessary
a. Unstageable - Unstageable refers to pressure injuries whose stage cannot be determined because eschar or slough obscures the wound. This wound has no eschar or slough
b. A suspected deep tissue injury - A suspected deep tissue injury refers to tissue that is discolored due to underlying tissue damage, boggy, and warm to the touch. If the skin is intact the injury appears as a blood-filled blister. If the skin is nonintact the wound bed will appear very dark in color.
c. Stage 4 - A stage 4 pressure injury has full-thickness tissue loss with destruction, tissue necrosis, and/or damage to muscle, bone, or supporting structures. There can be sinus tracts, deep pockets of infection, tunneling, undermining, and some eschar and slough
ATI - Wound Care
A nurse is caring for a client who has developed a stage 1
pressure injury in the area of the right ischial tuberosity. Whichof the following should the nurse plan to apply to the client’spressure injury?
a. Barrier creams
b. Antifungal ointment
c. Chemical debridement
d. Antibiotic agent
a. Barrier creams
Barrier creams and ointments are used for clients that are prone to skin breakdown from pressure, shear, or incontinence. Therefore, the nurse should plan to apply barrier creams for a client who has a stage 1 pressure injury
ATI - Wound Care
A nurse is caring for a client who has multiple sclerosis and a chronic nonhealing wound. The nurse should recognize that which of the following types of medications is known to delay wound healing?
a. Tricyclic antidepressants
b. Corticosteroids
c. Beta blockers
d. Anticholinergics
b. Corticosteroids
Corticosteroids suppress the immune system and can therefore delay wound healing
ATI - Wound Care
A nurse is documenting data about a deep necrotic wound on a client’s left buttock. The nurse observes a yellowish-tan, soft, stringy area of necrotic tissue formed in clumps and adhering firmly to the wound bed. Which of the following assessment findings should the nurse document?
a. Keloid
b. Slough
c. Granulation
d. Eschar
b. Slough
Slough is stringy necrotic tissue that appears whitish, yellowish, or tan in color and is firmly attached to the wound bed
a. Keloid - Keloids are hypertrophic scar tissue resulting from excessive collagen formation following a wound injury
c. Granulation - Granulation has a granular, moist, shiny, beefy, red appearance within the wound bed. This does not correlate with the nurse’s assessment findings
d. Eschar - Eschar is hard or soft necrotic tissue that is tan, black, or brown in color and is firmly attached to the wound bed
ATI - Wound Care
A nurse is selecting dressings for a client who has a full-thickness pressure injury and is experiencing considerable pain during dressing changes, despite administration of the prescribed analgesic prior to wound care. Which of the following types of dressings should the nurse select to help minimize the pain of dressing changes?
a. Wet-to-dry
b. Abdominal pads [ABD pad]
c. Dry gauze
d. Hydrogel
d. Hydrogel
The nurse should select hydrogel for this client because hydrogel does not adhere to the wound bed and maintains moisture, which results in decreased pain
a. Wet-to-dry dressings are usually painful to remove because, as the dressing dries, exudate, necrotic tissue, and healthy tissue adhere to the dressing and are pulled out when it is removed
b. ABD dressings are used over other dressings to absorb excess drainage and should not be place directly over a wound. This type of dressing can cause increased pain on removal when it is placed directly over an open wound
c. Gauze fibers can shed and adhere to the wound bed, causing painful removal
ATI - Wound Care
A nurse is caring for a client who has a stage 4 sacral pressure injury for which the provider has prescribed mechanical debridement. Which of the following is a form of mechanical debridement that the nurse should expect the client to receive?
a. Placing a transparent dressing over the pressure injury
b. Applying hydrocolloids to the wound bed
c. Pulsating lavage
d. Using a topical enzyme solution in the wound bed
c. Pulsating lavage
Pulsating lavage or irrigations provides mechanical debridement by dislodging exudate, debris, and necrotic tissue in the wound bed
a. Transparent dressing - A transparent film dressing protects a healing stage 1 pressure injury
b.Hydrocolloid - Hydrocolloids are an autolytic debridement using occlusive dressings
d. Topical enzyme solution is a form of chemical enzymatic debridement
ATI - Wound Care
A nurse is documenting data about a healing wound on a client’s lower leg. The predominant exudate in the wound is watery in consistency and light red in color. The nurse should document which of the following types of wound drainage?
a. Serosanguineous
b. Sanguineous
c. Serous
d. Purulent
a. Serosanguineous
This exudate is serosanguineous, which is thin and watery in consistency and pink to light red in color
b. Sanguineous - Sanguineous exudate is thin in consistency but bright red in color
c. Serous - Serous exudate is thin in consistency but clear in color
d. Purulent - Purulent exudate can be thin or thick in consistency, but it is tan to yellow in color
ATI - Wound Care
A nurse is caring for a client who has a heavy drainage from a moist red wound that is bleeding. Which of the following types of dressings should the nurse select to help promote hemostasis?
a. Transparent
b. Hydrogel
c. Alginate
d. Dry gauze
c. Alginate
Alginate dressings help establish hemostasis while providing a moist environment for healing and absorption of exudate. They do not adhere to the wound, so removal is unlikely to cause further bleeding.
a. Transparent - Transparent film dressings are used for clients who have a stage 1 pressure injury with minimal drainage
b. Hydrogel - Hydrogel dressings are used for clients who have a dry wound and minimal exudate
d. Dry gauze - Dry gauze can disrupt angiogenesis, the development of the vascular bed in the wound, thereby causing further bleeding of the wound when removed
ATI - Ostomy Care
A nurse is teaching a client who has a new ileostomy about preventing the excoriation and breakdown of the peristomal skin after they have returned home. Which of the following instructions should the nurse include?
a. Apply hydrocortisone cream to the skin when changing the appliance
b. Empty the pouch when it is LESS than 1/2 full
c. Wash the peristomal skin frequently with deodorizing soap and water
d. Choose a time shortly after a meal for replacing the pouch
b. Empty the pouch when it is LESS than 1/2 full
The nurse should instruct the client to empty the pouch when it is between 1/3 to 1/2 full because waiting to empty the pouch until it is more than 1/2 full increases the risk of leakage. Leakage of Ileostomy effluent is irritating to peristomal skin
a. The nurse should instruct the client to only use ostomy care products, such as skin sealants and ostomy skin creams, when changing the appliance
c. Clients should avoid the use of soap, especially oil- or lotion-based soaps, because they leave a residue that can interfere with pouch adhesion, thereby increasing the risk of leakage. The nurse should instruct the client to cleanse the skin with warm tap water only. In situations where soap is essential, and if the provider allows it, the client should only use a mild, pH-balanced soap
d. The nurse should instruct the client to change the pouch before a meal, when active bowel evacuation is less likely
ATI - Ostomy Care
A nurse is obtaining health history from a client who has a colostomy. The client reports frequent episodes of loose stools over the last month but has no signs of infection or bowel obstruction. The client tells the nurse that they have avoided participation in social activities because they are concerned about leakage. Which of the following should the nurse recommend?
a. Consume foods that are low in fiber content
b. Take an ounce of mineral oil twice a day
c. Add buttermilk and cranberry juice to the diet
d. Increase water intake to 3-3.5 L per day
a. Consume foods that are low in fiber content
The nurse should recommend that the client consume foods low in fiber to help thicken the stool. Examples of low-fiber foods include rice, noodles, white bread, and cheese
ATI - Ostomy Care
A nurse is teaching a client about extended-wear skin barriers. Which of the following strategies should the nurse instruct the client to use for maximal adherence?
a. Use an oil-based lotion on the peristomal area.
b. Apply the skin barrier while the skin is slightly moist.
c. Leave the residue from the previous appliance on the skin
d. Press gently around the barrier for 30 seconds to 1 min.
d. Press gently around the barrier for 30 seconds to 1 min
The nurse should instruct the client to press gently around to barrier for 30 seconds to 1 min because the pressure-sensitive tackifiers and heat-sensitive polymers of the skin barrier require adequate pressure and warmth (from the fingers) to ensure adherence
ATI - Ostomy Care
A nurse is replacing the ostomy appliance for a client whose newly created colostomy is functioning. After removing the pouch, which of the following actions should the nurse take first?
a. Measure the stoma
b. Cover the stoma with gauze
c. Remove the backing on the skin barrier
d. Cleanse the stoma and the peristomal skin
d. Cleanse the stoma and the peristomal skin
The first action the nurse should take is to remove any effluent adhering to the stoma and the peristomal skin to facilitate the assessment of the area
ATI - Ostomy Care
A nurse is reinforcing teaching with a client who has colon cancer and is scheduled for a procedure to remove their entire large intestine and rectum. The nurse should reinforce with the client that they are scheduled for which of the following types of ostomy procedure?
a. Cecostomy
b. Loop colostomy
c. Ileostomy
d. Descending colostomy
c. Ileostomy
After removing the entire large intestine and the rectum, the provider will create an ileostomy to divert feces from the small intestine to the abdominal surface and into an ostomy pouch
a. A cecostomy is a surgical opening created in the cecum, the first section of the large intestine, with an opening to the abdominal wall for diversion of feces. This is not possible if the entire large intestine is removed
b. A loop colostomy involves a large and usually temporary stoma that is created by pulling a loop of intestine onto the abdominal wall and creating two openings in the loop. This is not possible if the entire large intestine is removed
d. A descending colostomy is created by removing a portion of the descending colon and using the remaining section to create a stoma on the outer surface of the abdomen. This is not possible if the entire large intestine is removed.
ATI - Ostomy Care
A nurse is providing preoperative teaching for a client who is scheduled for creation of a sigmoid colostomy. Which of the following information should the nurse include in the teaching?
a. Expect the effluent from the sigmoid colostomy to be loose and continuous
b. Use irrigation to help establish a regular bowel pattern
c. Change the stoma’s appliance [pouch/bag] every other day
d. Expect effluent from the newly created stoma within 24 hr after sx
b. Use irrigation to help establish a regular bowel pattern
Clients with sigmoid colostomies can use irrigation to help control the passage of stool. Once the client has established a regular bowel pattern, the they can wear a stoma cap over the site, but they do not need an external appliance
a. With a sigmoid colostomy, the effluent is solid and formed. An ileostomy produces effluent that is loose and continuous
c. Ostomy appliances can remain in place for up to 7 days.
d. A client with a newly created colostomy should expect effluent to begin draining within 2 to 5 days after surgery. Clients who have had an ileostomy created can have drainage within 1 to 2 days
Txt Chapter - Nutrition
After administering an enteral feeding, a nurse evaluates the patient’s tolerance of the feeding. Which findings suggesting intolerance require collaboration with the dietician and health care provider? [Select all that apply]
Nausea and/or vomiting
Weight gain
Bowel sounds 20/min
200-mL gastric residual
Absence of diarrhea and constipation
Slight abdominal pain and distention
Nausea and/or vomiting
Bowel sounds 20/min
Absence of diarrhea and constipation
Criteria to consider when evaluating patient feeding tolerance include absence of nausea, vomiting, minimal or no gastric residual, absence of diarrhea and constipation, absence of abdominal pain and distention, presence of bowel sounds within normal limits
Txt Chapter - Nutrition
A nurse is feeding an older adult patient with dementia. What intervention will best promote nutritional intake?
a. Stroke the underside of the patient’s chin to promote swallowing.
b. Serve meals in different places and at different times.
c. Offer a whole tray of various foods to choose from.
d. Avoid between-meal snacks to ensure hunger at mealtime.
a. Stroke the underside of the patient’s chin to promote swallowing.
To feed a patient with dementia, the nurse should stroke the underside of the patient’s chin to promote swallowing, serve meals in the same place and at the same time, provide one food item at a time since a whole tray may be overwhelming, and provide between-meal snacks that are easy to consume using the hands.
Txt Chapter - Nutrition
A nurse is feeding a patient who is experiencing dysphagia. Which nursing intervention will best prevent aspiration?
a. Feed the patient solids first and liquids last.
b. Place the bed in the semi-Fowler position during feeding.
c. Provide a 30-minute rest period prior to mealtime.
d. Provide a straw for the patient’s beverages and soups.
c. Provide a 30-minute rest period prior to mealtime
The nurse should provide a 30-minute rest period prior to mealtime to promote better swallowing. The nurse alternates solids and liquids when feeding the patient; sits the patient upright or, if on bedrest, elevates the head of the bed at a 90-degree angle; and initiates a nutrition consult for diet modification and food size and/or consistency. Straws are avoided in patients with dysphagia. Assessing breath sounds will help detect aspiration but not prevent it
Txt Chapter - Nutrition
During interprofessional rounds, the charge nurse and health care provider evaluate patients to determine their need for parenteral nutrition (PN). Which patients will be identified as candidates for this type of nutritional support? [Select all that apply]
a. Patient with irritable bowel syndrome and intractable diarrhea
b. Patient with celiac disease not absorbing nutrients from the GI tract
c. Patient who is underweight and needs short-term nutritional support
d. Patient who is comatose and needs long-term nutritional support
e. Patient who has anorexia and refuses to take foods via the oral route
f. Patient with burns who has not been able to eat adequately for 5 days
a. Patient with irritable bowel syndrome and intractable diarrhea
b. Patient with celiac disease not absorbing nutrients from the GI tract
f. Patient with burns who has not been able to eat adequately for 5 days
Txt Chapter - Nutrition
A nurse is feeding a patient who reports feeling nauseated and unable to eat what is being offered. What would be the most appropriate initial action of the nurse in this situation?
a. Remove the tray from the room.
b. Administer an antiemetic and encourage the patient to take small amounts.
c. Explore why the patient does not want to eat the food.
d. Offer high-calorie snacks such as pudding and ice cream.
a. Remove the tray from the room.
The first action of the nurse when a patient has nausea is to remove the tray, which may have noxious odor, from the room. The nurse may then offer small amounts of foods and liquids such as crackers or ginger ale. The nurse may also administer a prescribed antiemetic and try small amounts of food when it takes effect
Txt Chapter - Nutrition
A nurse is receiving report on a patient with alcoholism who will be transferred to the medical-surgical unit. Due to long-term alcohol exposure, the nurse plans for administration of which nutrient?
a. B vitamins
b. Lipids
c. Fluids
d. C vitamins
a. B vitamins
The need for B vitamins is increased in alcoholism because these nutrients are used to metabolize alcohol, thus depleting their supply. Obesity, dehydration, and vitamin C deficiency may be present, but these are not directly related to the effect of alcohol on the GI trac
Txt Chapter - Nutrition
A nursing student is caring for a patient who had a gastrostomy tube placement 12 hours ago. Which action by the student is correct?
a. Using a cotton-tipped applicator dipped into sterile saline solution and gently cleaning around the insertion site
b. Washing the area surrounding the tube with a wet washcloth and with soap and water.
c. Adjusting the external disk every 3 hours to avoid crusting around the tube.
d. Taping a gauze dressing over the site after cleansing it.
e. Assessing the gastric residual every 4 hours.
f. Discontinuing feedings when gastric residual volume is 120 mL
a. Using a cotton-tipped applicator dipped into sterile saline solution and gently cleaning around the insertion site
Txt Chapter - Nutrition
A nurse is assessing a patient who has been NPO (nothing by mouth) prior to abdominal surgery. The patient is ordered a clear liquid diet for breakfast, to advance to a house diet as tolerated. Which assessments would indicate to the nurse that the patient’s diet should not be advanced?
a. The patient consumed 75% of the liquids on the breakfast tray.
b. The patient tells you they are hungry.
c. The patient’s abdomen is soft, nondistended, with bowel sounds.
d. The patient reports fullness and diarrhea after breakfast.
d. The patient reports fullness and diarrhea after breakfast.
Txt Chapter - Nutrition
A patient hospitalized for a stroke has a prescription for continuous tube feedings through a small-bore nasogastric tube. Following tube placement, which action by the nurse best confirms correct tube placement?
a. Auscultating the bowel sounds
b. Measuring the pH of gastric aspirate
c. Measuring the amount of residual in the stomach
d. Ensuring validation of tube placement by x-ray
d. Ensuring validation of tube placement by x-ray
Radiographic examination is the most accurate method to validate tube placement in the stomach. In addition, the length of the exposed tube is measured after insertion and documented. Tube length should be checked and compared with this initial measurement, in conjunction with the previous two methods for checking tube placement. Other methods that can be used are aspiration of gastric contents and measurement of the pH of the aspirate. Visual assessment of aspirated gastric contents is also suggested as a tool to check placement. The auscultatory method is considered inaccurate and unreliable. Measurement of residual volume amount does not confirm placement.
Txt Chapter - Nutrition
A nurse specializing in care of older adults speaks to a group of nursing students about that population’s challenge with obtaining sufficient nutrition. Which points will the nurse include in the discussion? [Select all that apply]
a. An increase in BMR and physical activity require additional calories.
b. Tooth loss and periodontal disease may make chewing more difficult.
c. Decreased peristalsis can result in constipation, requiring additional fiber and fluid.
d. Loss of taste between sweet and salty occurs with a preference for sweets.
e. Older adults express an increase thirst sensation.
f. Caloric needs decrease, and the need for nutrients increases, especially protein.
b. Tooth loss and periodontal disease may make chewing more difficult.
c. Decreased peristalsis can result in constipation, requiring additional fiber and fluid.
d. Loss of taste between sweet and salty occurs with a preference for sweets.
f. Caloric needs decrease, and the need for nutrients increases, especially protein.
Txt Chapter - Nutrition
A nurse performs presurgical assessments of patients in an ambulatory care center. Which patient assessment requires collaboration with the surgeon, as the procedure could need to be postponed?
a. 19-year-old patient who is a vegan
b. Older adult patient who takes daily nutritional drinks
c. 43-year-old patient who takes ginkgo biloba and an aspirin daily
d. Infant who is breastfeeding
c. 43-year-old patient who takes ginkgo biloba and an aspirin daily
Txt Chapter - Nutrition
A nurse is caring for a patient with ill-fitting dentures. What modification to their diet will the nurse suggest?
a. Clear liquid
b. Full liquid
c. Mechanically altered
d. Honeylike liquids
c. Mechanically altered
Mechanically altered diets provide adequate in calories and nutrients and contain chopped, ground, or soft foods. Liquid diets are generally used as transitional diets when eating resumes after acute illness, surgery, or parenteral nutrition. Clear-liquid diets are inadequate in calories, protein, and most nutrients; progression to more nutritious alternatives is recommended as soon as possible. Full-liquid diets include clear liquids plus milk and milk drinks, puddings, custards, plain frozen desserts, pasteurized eggs, cereal gruels, vegetable juices, and milk and egg substitutes in addition to clear liquids. A high-calorie, high-protein supplement is recommended if a full-liquid diet is used for more than 3 days
Txt Chapter - Urinary Elimination
A new graduate nurse and their preceptor must collect several urine specimens for laboratory testing. Which techniques for urine collection by the graduate nurse are performed incorrectly, requiring the preceptor to intervene? [Select all that apply]
a. Catheterizing a patient to collect a sterile urine sample for routine urinalysis
b. Collecting a clean-catch urine specimen in the morning and storing it at room temperature until an afternoon pick-up
c. Collecting a sterile urine specimen from the collection bag of a patient’s indwelling catheter
d. Collecting about 3 mL of urine from a patient’s indwelling catheter to send for a urine culture
e. Planning to collect a sterile specimen from a patient with a urinary diversion by catheterizing the stoma
f. Discarding the first urine of the day when performing a 24-hour urine specimen collection on a patient
a. Catheterizing a patient to collect a sterile urine sample for routine urinalysis
b. Collecting a clean-catch urine specimen in the morning and storing it at room temperature until an afternoon pick-up
c. Collecting a sterile urine specimen from the collection bag of a patient’s indwelling catheter
**A sterile specimen is not required for a routine urinalysis. Urine chemistry is altered after urine stands at room temperature for a long period of time. A specimen from the collection drainage bag may not be fresh urine and could result in inaccurate analysis.
**
Txt Chapter - Urinary Elimination
A nurse caring for older adults in an extended-care facility performs regular assessments of the patients’ urinary functioning. Which patients would the nurse identify as at risk for urinary retention? [Select all that apply]
a. Patient who is diagnosed with an enlarged prostate
b. Patient who is on bedrest
c. Patient who is diagnosed with vaginal prolapse
d. Older adult patient with dementia
e. Patient who is taking antihistamines to treat allergies
f. Patient who has difficulty walking to the bathroom
a. Patient who is diagnosed with an enlarged prostate
c. Patient who is diagnosed with vaginal prolapse
e. Patient who is taking antihistamines to treat allergies
Urinary retention occurs when urine is produced normally but is not excreted completely from the bladder. Factors associated with urinary retention include medications such as antihistamines, an enlarged prostate, or vaginal prolapse. Being on bedrest, having dementia, and having difficulty walking to the bathroom may place patients at risk for** urinary incontinence.**
Txt Chapter - Urinary Elimination
A nurse in the gynecology clinic is preparing an educational brochure to teach patients how to prevent UTIs. Which teaching points would the nurse include? [Select all that apply]
a. Wear underwear with a cotton crotch.
b. Take baths rather than showers.
c. Drink of six to eight 8-oz glasses of liquid per day.
d. Urinate before and after intercourse.
e. After defecation, dry the perineal area from the front to the back.
f. Observe the urine for color, amount, odor, and frequency.
a. Wear underwear with a cotton crotch.
c. Drink of six to eight 8-oz glasses of liquid per day.
d. Urinate before and after intercourse.
e. After defecation, dry the perineal area from the front to the back.
Txt Chapter - Urinary Elimination
A patient who has pneumonia has had a fever for 3 days. What characteristics would the nurse anticipate related to the patient’s urine output?
a. Decreased amount and highly concentrated
b. Decreased amount and very pale like water
c. Increased amount and very concentrated
d. Increased amount and dilute appearing
a. Decreased amount and highly concentrated
Fever and diaphoresis cause the kidneys to conserve body fluids. Thus, the urine is concentrated and decreased in amount.
Txt Chapter - Urinary Elimination
The health care provider has ordered an indwelling catheter to be inserted to relieve urinary retention in a male patient with prostate enlargement. What consideration will the nurse keep in mind when performing this procedure?
a. The male urethra is more vulnerable to injury during insertion.
b. In the hospital, a clean technique is used for catheter insertion.
c. The catheter is inserted 2 to 3 inches into the meatus.
d. Since it uses a closed system, the risk for UTI is absent.
a. The male urethra is more vulnerable to injury during insertion.
Txt Chapter - Urinary Elimination
A nurse is caring for a patient with an enlarged prostate who has had an indwelling catheter for several weeks. A prescription for continuous bladder irrigation (CBI) is written after the patient developed hematuria post cystoscopy. The nurse teaches the patient the purpose of CBI is to prevent what situation?
a. Catheter infection due to long-term use
b. Need to flush the catheter of organisms post procedure
c. Blood clots that could block the catheter
d. Need for increased fluid intake
c. Blood clots that could block the catheter
Post procedure continuous bladder irrigation, in the presence of hematuria, prevents stasis of blood and clot formation potentially obstructing urine output. In the absence of hematuria, clots or debris, natural irrigation of the catheter through increased fluid intake by the patient is preferred. It is preferable to avoid catheter irrigation unless necessary to relieve or prevent obstruction
Txt Chapter - Urinary Elimination
A nurse is caring for a patient who has a urinary diversion (urostomy) after cystectomy (removal of the bladder) to treat bladder cancer. What interventions are indicated for this patient? [Select all that apply]
a. Measuring the patient’s fluid intake and output
b. Keeping the skin around the stoma moist
c. Emptying the appliance frequently
d. Reporting any mucus in the urine to the primary care provider
e. Encouraging the patient to look away when changing the appliance
f. Monitoring the return of intestinal function and peristalsis
a. Measuring the patient’s fluid intake and output
c. Emptying the appliance frequently
f. Monitoring the return of intestinal function and peristalsis
Txt Chapter - Urinary Elimination
A nurse is changing the stoma appliance on a patient’s ileal conduit. Which finding requires the nurse to follow up with the provider?
a. Stoma is moist.
b. Skin around the stoma is irritated.
c. Urine is leaking from the stoma.
d. Stoma is a purple-black color.
d. Stoma is a purple-black color.
The stoma should appear pink to red, shiny, and moist; a dark brown or purple-blue stoma may reflect compromised circulation. The nurse contacts the health care provider immediately. A urostomy is incontinent; urine leakage is expected.
Txt Chapter - Urinary Elimination
A postoperative patient is having difficulty voiding and reports suprapubic pressure. What action can the nurse take to promote voiding?
a. Pouring cold water over the patient’s fingers and perineum
b. Assessing bladder residual using the bladder scanner
c. Immediately encouraging the patient to void
d. Recommending an indwelling catheter
b. Assessing bladder residual using the bladder scanner
Factors associated with urinary retention include medications, an enlarged prostate, and vaginal prolapse. Assist the patient to void when the patient first feels the urge. Assessing for residual urine will not promote voiding; rather, it will determine the volume of urine in the bladder. Cold water would cause the patient to tighten their muscles.
Txt Chapter - Urinary Elimination
A nurse is caring for an alert, ambulatory, older adult with urinary frequency who has difficulty making it to the bathroom in time. Which nursing intervention is most appropriate to include in the care plan for this patient?
a. Explaining that incontinence is an expected occurrence with aging
b. Asking the patient’s family/caregivers to purchase incontinence pads for the patient
c. Teaching the patient how to perform PFMT exercises at regular intervals
d. Inserting an indwelling catheter to prevent skin breakdown
c. Teaching the patient how to perform PFMT exercises at regular intervals
Pelvic floor exercises (Kegel exercises) may help a patient regain control of the micturition. Incontinence is not a normal consequence of aging. Using absorbent products may remove motivation from the patient and caregiver to seek evaluation and treatment of the incontinence; they should be used only after careful evaluation by a health care provider. Due to risk for infection, an indwelling catheter is the last choice of treatment.
Txt Chapter - Urinary Elimination
A nurse is caring for a male patient who had a urinary sheath applied following hip surgery. What nursing interventions are appropriate to include when caring for this patient? [Select all that apply]
a. Preventing the tubing from kinking to maintain free urinary drainage
b. Changing the sheath weekly and provide hygiene
c. Fastening the sheath tightly to prevent the possibility of leakage
d. Having the patient maintain bedrest to prevent the sheath from slipping off
e. Leaving 1 to 2 inches (2.5 to 5 cm) beyond the tip of the penis
f. Ensuring the device does not restrict blood flow.
a. Preventing the tubing from kinking to maintain free urinary drainage
e. Leaving 1 to 2 inches (2.5 to 5 cm) beyond the tip of the penis
f. Ensuring the device does not restrict blood flow.
Txt Chapter - Urinary Elimination
A nurse receives a prescription to catheterize a patient following surgery. What nursing action reflects correct technique?
a. Planning to use different equipment for catheterization of male versus female patients
b. Selecting the smallest appropriate size indwelling urinary catheter
c. Sterilizing the equipment prior to insertion
d. Avoiding filling the balloon with sterile water to prevent pressure on tissues
b. Selecting the smallest appropriate size indwelling urinary catheter
The smallest appropriate indwelling urinary catheter should be selected to aid in prevention of CAUTIs in the adult hospitalized patient. The equipment used for catheterization is usually prepackaged in a sterile, disposable tray and is the same for both male and female patients. Most kits already contain a standard-sized catheter. Catheters are graded on the French (F) scale according to lumen size, with 12 to 16Fr gauge commonly used. A 14F, 5-mL or 10-mL balloon is usually appropriate, unless ordered otherwise.
Txt Chapter - Urinary Elimination
A nurse in the emergency room is teaching a patient how to collect a midstream urine specimen. What instructions will the nurse give the patient? [Select all that apply]
a. Wash your hands with soap and water.
b. Open the container and place the lid face down on the counter.
c. Separate your labia and wipe with the antiseptic towelettes in the kit.
d. Without letting go of the labia, void a small amount into the toilet or collection hat.
e. Lean the collection container against the urinary opening and void into the container.
f. Void an ounce, then remove the container and finish voiding in the toilet.
a. Wash your hands with soap and water.
c. Separate your labia and wipe with the antiseptic towelettes in the kit.
d. Without letting go of the labia, void a small amount into the toilet or collection hat.
The nurse gives these instructions to collect the midstream/clean-catch urine specimen: Wash your hands with soap and water. Open the collection cup, and place the lid face up; do not touch the inside. Separate the labia and cleanse the urinary opening with soap and water or towelettes included in the kit. Void about 1 oz. (30 mL) into the toilet, then move the collection cup close to the urinary opening and void about 1 oz (no less than 2 teaspoons) into the container. Pass the remainder of the urine into the toilet. Without touching the inside of the lid, close the cup and return it to the nurse.
Txt Chapter - Urinary Elimination
A nursing student hears in report that their patient is receiving a nephrotoxic medication. The student plans care to include what action?
a. Teaching the patient to expect increased voiding
b. Assessing for kidney damage
c. Preventing urinary incontinence
d. Observing for nocturia
b. Assessing for kidney damage
Nephrotoxic medications are those capable of causing kidney damage. The nurse can assess I&O, quality of the urine, and renal function blood tests to detect this problem. Urinary frequency, incontinence, and getting up at night to void (nocturia) are not effects of nephrotoxic medications
Txt Chapter - Bowel Elimination
A nurse is performing an abdominal assessment on a patient experiencing frequent bouts of diarrhea. The nurse first observes the contour of the abdomen, noting any masses, scars, or areas of distention. What action will the nurse perform next?
a. Auscultating the abdomen using an orderly clockwise approach in all abdominal quadrants
b. Percussing all quadrants of the abdomen in a systematic clockwise manner to identify masses, fluid, or air in the abdomen
c. Lightly palpating over the abdominal quadrants; first checking for any areas of pain or discomfort
d. Deeply palpating over the abdominal quadrants, noting muscular resistance, tenderness, organ enlargement, or masses
a. Auscultating the abdomen using an orderly clockwise approach in all abdominal quadrants
The sequence for abdominal assessment proceeds from inspection, auscultation, percussion, and then palpation. Inspection and auscultation are performed before palpation because palpation may disturb normal peristalsis and bowel motility.
Txt Chapter - Bowel Elimination
A nurse working on a GI unit is caring for a group of patients. In patients with which health problems or issues could the assessment possibly reveal decreased or absent bowel sounds after listening for 2 minutes? [Select all that apply]
a. Peritonitis
b. Prolonged bedrest
c. Diarrhea
d. Gastroenteritis
e. Early bowel obstruction
f. Postoperative paralytic ileus
a. Peritonitis
b. Prolonged bedrest
f. Postoperative paralytic ileus
Decreased or absent bowel sounds—documented only after listening for in the epigastric and umbilical area of the abdomen for 2 minutes or longer (Bickley et al., 2021)—signify the absence of bowel motility, commonly associated with peritonitis, paralytic ileus, and/or prolonged immobility. Hyperactive bowel sounds indicate increased bowel motility, commonly caused by diarrhea, gastroenteritis, or early bowel obstruction
Txt Chapter - Bowel Elimination
A nurse in a long-term care facility is assessing a group of patients. In which patients would the nurse anticipate increased risk for developing diarrhea? [Select all that apply]
a. Patient taking opioids for pain
b. Patient taking metformin for type 2 diabetes
c. Patient taking diuretics
d. Patient who developed dehydration
e. Patient taking amoxicillin clavulanate for infection
f. Patient taking magnesium-containing antacids
b. Patient taking metformin for type 2 diabetes
e. Patient taking amoxicillin clavulanate for infection
f. Patient taking magnesium-containing antacids
Diarrhea is a potential adverse effect of treatment with amoxicillin clavulanate, metformin, or antacids containing magnesium. Opioids, diuretics, and dehydration may lead to constipation
Txt Chapter - Bowel Elimination
A nurse prepares to assist a patient with a newly created ileostomy. Which recommended patient teaching points would the nurse stress? [Select all that apply]
a. “When you inspect the stoma, it should be dark purple-blue.”
b. “The size of the stoma will stabilize within 2 weeks.”
c. “Keep the skin around the stoma site clean and moist.”
d. “The stool from an ileostomy is normally liquid.”
e. “Eat dark-green vegetables to control the odor of the stool.”
f. “You may have a tendency to develop food blockages.”
d. “The stool from an ileostomy is normally liquid.”
e. “Eat dark-green vegetables to control the odor of the stool.”
f. “You may have a tendency to develop food blockages.”
Ileostomies normally have liquid, foul-smelling stool. The nurse should encourage intake of dark-green vegetables for their chlorophyll content, which helps to deodorize the feces. Explain that patients with ileostomies may tend to develop food blockages, especially when high-fiber foods are consumed. The stoma should be dark pink to red and moist. Stoma size usually stabilizes within 4 to 6 weeks, and the skin around the stoma site (peristomal area) should be kept clean and dry.
Txt Chapter - Bowel Elimination
A nurse is caring for a patient who had abdominal surgery and has a nasogastric tube attached to low suction. Which nursing actions are appropriate when caring for this patient? [Select all that apply]
a. Irrigating the tube with 30-mL normal saline solution
b. Confirming tube placement via pH testing of gastric secretions
c. Positioning the air vent at the level of the patient’s umbilicus
d. Instilling irrigation via the blue air vent
e. Monitoring the patient’s abdomen for distention
f. Documenting the nasogastric irrigation and drainage with I & O
a. Irrigating the tube with 30-mL normal saline solution
b. Confirming tube placement via pH testing of gastric secretions
d. Instilling irrigation via the blue air vent
e. Monitoring the patient’s abdomen for distention
f. Documenting the nasogastric irrigation and drainage with I & O
Care of a patient with an NG tube connected to suction includes verifying placement before administration of any fluids or medications to avoid aspiration. Radiographic evidence of the tip of the tube in the stomach, measurement of tube length, measurement of tube marking, measurement of aspirate pH, and carbon dioxide monitoring may be used. The nurse irrigates the tube with 30 mL of saline solution (or as prescribed/ per policy) with an irrigating syringe. The nurse separates the tube from the suction device, clamps the NG tube to prevent gastric secretions from leaking, and places the tip of the syringe in the tube to gently insert the saline solution. The nurse should not place irrigant in the blue air vent of a Salem sump or double-lumen tube; rather, the nurse should instill air through the vent. The air vent decreases any pressure that has built up in the stomach during suction; instilling air promotes drainage. The air vent should be placed above the stomach. Abdominal distention may indicate lack of proper drainage or delayed return of GI function. The nurse documents all irrigation and NG tube output with the I & O. If the nurse allows the irrigant to drain out, that is excluded from intake.
Txt Chapter - Bowel Elimination
A nurse is planning a bowel program for a patient with frequent constipation after sustaining a spinal cord injury. What is the first step the nurse will take?
a. Offering a diet that is low in residue
b. Increasing fluid intake to 3,000 mL daily
c. Administering daily enemas to stimulate peristalsis
d. Assessing the patient’s bowel patterns
d. Assessing the patient’s bowel patterns
The nurse follows the steps of the nursing process to plan care. First the nurse assesses the patient’s bowel movements including frequency, consistency, shape, volume, and color. Based on the assessment findings, the nurse may recommend 3 of fluid daily or administer an enema, as appropriate. The nurse also monitors bowel sounds, teaches about specific foods that promote bowel regularity, ensures privacy, and encourages adequate fluid intake.
Txt Chapter - Bowel Elimination
A community health nurse is providing an adult education session about colon cancer. Which signs and symptoms of this cancer will the nurse include? [Select all that apply]
a. Blood in the stool
b. Previous colonoscopy
c. Passing two large bowel movements daily
d. Unintentional weight loss
e. Upper abdominal cramping
f. Previous opioid use
a. Blood in the stool
d. Unintentional weight loss
Txt Chapter - Bowel Elimination
For a patient with which health problem or issue would a nurse expect the health care provider to order colostomy irrigation?
a. IBS
b. Left-sided end colostomy in the sigmoid colon
c. Postradiation damage to the bowel
d. Crohn disease
b. Left-sided end colostomy in the sigmoid colon
Irrigations are used to promote regular evacuation of distal colostomies. Colostomy irrigation may be indicated in patients who have a left-sided end colostomy in the descending or sigmoid colon, are mentally alert, have adequate vision, and have adequate manual dexterity needed to perform the procedure. Contraindications include IBS, peristomal hernia, postradiation damage to the bowel, diverticulitis, and Crohn disease
Txt Chapter - Bowel Elimination
A nurse is assisting a patient to change an ostomy appliance when they note the stoma is protruding into the bag. What would be the nurse’s first action in this situation?
a. Reassuring the patient that this is a normal with a new ostomy
b. Notifying the health care provider that the stoma is prolapsed
c. Having the patient rest for 30 minutes to see if the prolapse resolves
d. Replacing the appliance with a larger appliance
c. Having the patient rest for 30 minutes to see if the prolapse resolves
If the stoma protrudes into the bag after changing the ostomy appliance, the nurse should have the patient rest for 30 minutes. If the stoma is not back to normal size within that time, notify the health care provider. If the stoma stays prolapsed, it may twist, resulting in impaired circulation to the stoma.
Txt Chapter - Bowel Elimination
A nurse asks a patient for a stool sample to perform the guaiac test. How does the nurse best explain the purpose of this test?
a. “This test replaces the need for screening colonoscopy.”
b. “We are looking for infectious organisms in your stool.”
c. “The screening assesses for blood in your stool.”
d. “This test assesses for antibodies to colon cancer.”
c. “The screening assesses for blood in your stool.”
The guaiac fecal occult blood testing (FOBT) is used to detect occult blood in the stool. It is used for initial/early screening for disorders such as cancer and for GI bleeding in conditions such as ulcer disease, inflammatory bowel disorders, and intestinal polyps. A positive FOBT result indicates that abnormal bleeding is occurring somewhere in the digestive tract.
Txt Chapter - Wound Care / Skin Integrity
Thirty-six hours after having surgery, a patient has a slightly elevated body temperature and generalized malaise as well as pain with redness at the surgical site. Which action is most appropriate?
MAR
Acetaminophen 650 mg every 6 hours prn fever
Cefazolin (antibiotic) 1 g 1 hour preoperatively
Cefazolin 1 g, every 6 hours 3 times, postoperatively
a. Documenting the findings and continuing to monitor the patient
b. Administering antipyretics and contacting the provider for an antibiotic prescription
c. Increasing the frequency of assessment to every hour and notifying the patient’s primary care provider
d. Obtaining a wound culture and increasing the frequency of wound care
a. Documenting the findings and continuing to monitor the patient
Txt Chapter - Wound Care / Skin Integrity
A nurse on a surgical unit has assessed and documented a patient’s wound and drainage. Which statements most accurately describe the characteristic of the wound drainage?
Graphic Record
T 99.9 P100 RR 20 BP 138/88
Nursing note: Patient postoperative day 2. Dry sterile dressing changed on abdominal incision. Incision edges are well approximated with a slight ½-cm opening at inferior edge; incisional edges reddened. Hemovac draining sanguineous material, 60 mL for the shift. Patient reports moderate pain, relieved by oxycodone X1.
a. Sanguineous drainage is composed of the clear portion of the blood and serous membranes.
b. Sanguineous drainage is composed of a large number of red blood cells and looks like blood.
c. Sanguineous drainage is composed of white blood cells, dead tissue, and bacteria.
d. Sanguineous drainage is thin, cloudy, and watery and may have a musty or foul odor
b. Sanguineous drainage is composed of a large number of red blood cells and looks like blood.
Txt Chapter - Wound Care / Skin Integrity
A postoperative patient who has a large abdominal incision suddenly calls out for help, shouting, “Something is falling out of my incision!” The nurse notes the wound is gaping open with tissue bulging outward. Place the nursing interventions in the order they should be performed, arranged from first to last.
- Notify the health care provider of the situation.
- Cover exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution.
- Place the patient in the low Fowler position.
- Document the findings and outcome of interventions.
- Maintain NPO status for return to the OR for repair.
- C - Place the patient in the low Fowler position.
- B - Cover exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution.
- A - Notify the health care provider of the situation.
- E - Maintain NPO status for return to the OR for repair.
- D - Document the findings and outcome of interventions.
Txt Chapter - Wound Care / Skin Integrity
A patient is admitted with a nonhealing surgical wound. Which nursing interventions will the nurse use to promote wound healing? [Select all that apply]
a. Applying sterile dressing supplies
b. Discussing zinc supplementation with the health care provider
c. Maintaining bedrest
d. Performing careful hand hygiene
e. Teaching the patient to increase protein in the diet
f. Suggesting the patient consume vitamin C–containing foods.
a. Applying sterile dressing supplies
b. Discussing zinc supplementation with the health care provider
d. Performing careful hand hygiene
e. Teaching the patient to increase protein in the diet
f. Suggesting the patient consume vitamin C–containing foods
Txt Chapter - Wound Care / Skin Integrity
A nurse is developing a care plan for an older adult patient who is recovering from a hip arthroplasty (hip replacement). Which assessment findings indicate a high risk for this patient to develop area(s) of pressure injury? [Select all that apply]
a. The patient takes time to think about responses to questions.
b. The patient is an older adult with a poor appetite.
c. The patient reports inability to control their urine.
d. The patient’s albumin level is <3.2 mg/dL (normal, 3.4 to 5.4 g/dL).
e. Lab findings include BUN 12 (older adult, normal 8 to 23 mg/dL) and creatinine 0.9 (adult female, normal 0.61 to 1 mg/dL).
f. The patient reports increased pain in right hip when repositioning in bed or chair.
b. The patient is an older adult with a poor appetite.
c. The patient reports inability to control their urine.
d. The patient’s albumin level is <3.2 mg/dL (normal, 3.4 to 5.4 g/dL).
f. The patient reports increased pain in right hip when repositioning in bed or chair.
Txt Chapter - Wound Care / Skin Integrity
A nurse is explaining to a patient the anticipated effect of the application of cold to an injured area. What response indicates that the patient understands the explanation?
a. “There will be more discomfort in the area where the cold is applied.”
b. “I should expect more drainage from the incision after the ice has been in place.”
c. “Redness and swelling should decrease after cold treatment.”
d. “My incision may bleed more when the ice is first applied.”
c. “Redness and swelling should decrease after cold treatment.”
[The local application of cold constricts peripheral blood vessels, reduces muscle spasms, and promotes comfort. Cold reduces blood flow to tissues, decreases the local release of pain-producing substances, decreases metabolic needs, and capillary permeability. The resulting effects include decreased edema, coagulation of blood at the wound site, promotion of comfort, decreased drainage from wound, and decreased bleeding.]
Txt Chapter - Wound Care / Skin Integrity
A nurse is providing education to a patient and their family regarding the use of negative pressure wound therapy (NPWT). The nurse documents that the teaching has been effective when the patient and family make which statement?
a. “This therapy is used to collect excess blood loss and prevent formation of a scab.”
b. “The suction created will prevent infection and promote wound healing with less scar tissue.”
c. “Suction stimulates blood flow to the wound, removes excess fluid, and promotes a moist environment for healing.”
d. “This treatment irrigates the wound, suctions the irrigation fluid from the wound, and keeps it free from debris wound exudate.”
c. “Suction stimulates blood flow to the wound, removes excess fluid, and promotes a moist environment for healing.”
Txt Chapter - Wound Care / Skin Integrity
After an initial skin assessment, the nurse documents the presence pressure area that is reddened and has a 1-cm blister. How will the nurse document the wound stage?
a. Stage 1 dark maroon wound, skin intact
b. Stage 2 with 1-cm blister noted
c. Stage 3 wound base with red granulation tissue
d. Stage 4 blanchable reddened area, 2 cm
b. Stage 2 with 1-cm blister noted
BLISTER = STAGE 2
Txt Chapter - Wound Care / Skin Integrity
A nurse notes a pressure wound base is red. Using the RYB system for documentation, what intervention is indicated?
a. Irrigating the wound and applying an absorbent dressing
b. Gently cleansing the wound and applying a moist dressing
c. Discussing consultation for surgical debridement with the provider
d. Performing frequent dressing changes to keep the wound and dressing dry
b. Gently cleansing the wound and applying a moist dressing
Txt Chapter - Wound Care / Skin Integrity
A nurse is developing education for nurses and UAPs related to prevention of pressure injuries for residents in a long-term care facility. Which action to prevent pressure injury will the nurses delegate to the UAP?
a. Maintaining the head of the bed elevated consistently
b. Massaging over bony prominence
c. Repositioning bedbound patients every 4 hours
d. Using a mild cleansing agent when cleansing the skin
d. Using a mild cleansing agent when cleansing the skin
Txt Chapter - Wound Care / Skin Integrity
Determine the patient’s risk for pressure injury using the Braden scale, based on information in the electronic health record (EHR).
EHR 1430 Admission Assessment
S: Patient admitted from nursing home for sepsis, confusion, ambulatory dysfunction.
B: 87-year-old patient, with history of heart failure and hypertension; comes to ED with shortness of breath and yellow sputum.
A: Lungs with crackles, pale, short of breath on exertion, pulse oximetry 88%, skin fragile.
Bedrest maintained. States has not eaten or drank fluids for last 36 hours; incontinent of small amounts of urine × 2. Responding to painful stimuli, not participating in turning or care.
R: Need orders for oxygen, sputum culture, activity level. Consider IV fluids. J. Smith RN.
No risk
Moderate risk
High risk
Very high risk
VERY HIGH RISK
**The patient is at very high risk for pressure injury. This patient responds only to painful stimulate (1); is occasionally moist (3); is bedridden (1); has not eaten (1), and requires maximum assistance for moving (1) for a total of 7 points. The Braden scale scoring is: a score of 19 to 23 indicates no risk; 15 to 18, mild risk; 13 to 14, moderate risk; 10 to 12, high risk; and 9 or lower, very high risk (Braden & Maklebust, 2005). In addition, nurses use clinical judgment to incorporate risk factors and/or other health problems into preventative interventions.
**
Txt Chapter - Wound Care / Skin Integrity
The nurse is caring for a patient 1 day postoperative abdominal surgery. The nurse identifies the patient is at risk for wound dehiscence. What patient risk factor is consistent with development of this problem?
a. Cigar smoker
b. Wound drainage 120 mL over 24 hours
c. Height, 5′ 6″ and weight 240 lb
d. WBC count 9,500 c/mm3
a. Cigar smoker
Lecture - NG / Bowel Case Study
The X-ray image is most consistent with a patient who has which of the following symptoms in their immediate hx?
a. An increase in watery stool frequency and amount
b. A decrease in stool quantity and amount
c. Bloody stools
d. Excessive flatulence
b. A decrease in stool quantity and amount
X-RAY SHOWS COLON WITH BACKED UP FECES = CONSTIPATED
Lecture - NG / Bowel Case Study
Which of the following symptoms likely match the rest of the patient hx we have so far? [Select all that apply]
a. Hyperactive bowel sounds
b. Pain in the abdomen
c. Distension
d. Hypoactive bowel sounds
b. Pain in the abdomen
c. Distension
d. Hypoactive bowel sounds
Lecture - NG / Bowel Case Study
What are ‘normal’ discharge instructions to follow at home for CONSTIPATION?
IT IS EASIER TO PREVENT THAN TO TREAT
PREVENTION:
* Increase fiber
* Increase fluids
* Increase activity
* Medications - stool softeners vs laxatives
* Warm prune juice if normal regimen starts to get off track
Lecture Review
You are admitting a client to the med-surg unit for CHF exacerbation. The patient usually wears dentures but forgot to bring them to the hospital. Which diet may be most appropriate until the patient’s family can bring the denture in the AM?
a. Nectar thick liquids
b. Clear liquid
c. Full liquid
d. Mechanical soft
d. Mechanical soft
Lecture Review
A homecare nurse is assisting a client with breakfast who has a history of CVA with dysphagia. Which of the following are important protective feeding strategies the nurse can include? [Select all that apply]
a. Sit client at 45 degree angle
b. Follow recommendations from SLT about fluid/food consitencies
c. Have client seated in high-Fowler’s during and at least 30 min after meal
d. Provide small bites of foot for patient as tolerated
e. Inspect the client’s oral cavity after each bite for pocketing
b. Follow recommendations from SLT about fluid/food consitencies
c. Have client seated in high-Fowler’s during and at least 30 min after meal
d. Provide small bites of foot for patient as tolerated
e. Inspect the client’s oral cavity after each bite for pocketing
Lecture Review
A nurse is preparing to administer a bolus feed to a client with a NG tube to R nare. The nurse was unable to aspirate gastric contents to check GVR. What action should the nurse take next?
a. Administer gingerale or carbonated beverage in the tube to break the clog
b. Push as hard as possible to push the clog along
c. Get warm water and gently apply pressure by pushing and pulling back with a syringe
d. Remove tube and place a new one
c. Get warm water and gently apply pressure by pushing and pulling back with a syringe
Lecture Review
A nurse is caring for a client with dysphagia who requires feeding via small bore Dobhoff which has just been inserted on the ICU floor. Which of the following best confirms tube placement?
a. pH level from gastric aspirate
b. Measure of GVR
c. Auscultating bowel sounds
d. Abdominal x-ray
d. Abdominal x-ray
Lecture Review
A client is newly post operative from bowel resection and has been NPO. They are now approved for diet progression as tolerated. Which of the following would indicate that diet should not be advanced after trying clear liquids?
a. Client consumes 60% of liquids on their meal tray
b. Abdomen soft, non-tender, BS present
c. The client reports fullness and watery stool
d. The client reports feeling hungry
c. The client reports fullness and watery stool
Lecture Review
A client with COPD is experiencing significant weight loss due to easy fatigue during large meal times. Which of the following suggestions by the nurse can support intake for this patient?
a. Reinforce the importance of eating all foods on the meal tray
b. Administering pain medication before meals
c. Performing respiratory tx just before meals
d. Offer small, more frequent meals
d. Offer small, more frequent meals
Lecture Review
A nurse is performing a medication administration pass for a client who was admitted to the med-surg floor last night at 3am. The nurse offers a medication cup with 1 acetaminophen tablet and water with a straw. Which of the following may indicate the client is experiencing dysphagia? [Select all that apply]
a. Water and saliva dribbling from corner of mouth
b. The client asking what the medication is for
c. The client begins to cough after swallowing
d. The client continuously ‘throat clears’ during their conversation after
e. The clients voice sounds ‘wet’
a. Water and saliva dribbling from corner of mouth
c. The client begins to cough after swallowing
d. The client continuously ‘throat clears’ during their conversation after
e. The clients voice sounds ‘wet’
Lecture Review
A nurse is preparing to assist a client with a meal who has advanced dementia. Which of the following may best promote intake of nutrition?
a. Avoid snacks to ensure hunger at designated meal times
b. Set up meals at different times and locations each time
c. Gently stroke underside if chin to promote swallowing
d. Offer many food options for the client to choose from
c. Gently stroke underside if chin to promote swallowing
Lecture Review
Blood in urine
Hematuria
Lecture Review
Produces large volumes of urine
Polyuria
Lecture Review
Trouble initiating or maintaining a stream of urine
Hesitancy
Lecture Review
Produces small amounts of urine
Oliguria
Lecture Review
Urine in the urethra that leaks out after stopping a stream
Dribbling
Lecture Review
Urination at night [ or ‘sleeping hours’ ]
Nocturia
Lecture Review
The nurse cares for a 19-year-old wheelchair bound male [paraplegia secondary to spinal cord injury] who has come in to the clinic with his mother for a routine checkup.
Which findings are of most concern to the nurse? [Select all that apply]
a. Hypoactive bowel sounds
b. Red, open area on heel
c. Full active ROM in bilateral upper extremities & Full passive ROM in bilateral lower extremities
d. 112/68 bp
e. Light touch sensation intact in fingers
f. Foul odor [from wound on left heel]
g. Absence of feeling below the waist
Open area on heel
Foul odor
Lecture Review
For each finding - indicate if the finding is consistent with pressure injury or venous stasis ulcer:
IMMOBILITY
BOTH
PRESSURE INJURY + VENOUS STASIS ULCER
Lecture review
For each finding - indicate if the finding is consistent with pressure injury or venous stasis ulcer:
INADEQUATE CALF MUSCLE FUNCTION
VENOUS STASIS ULCER
Lecture Review
For each finding - indicate if the finding is consistent with pressure injury or venous stasis ulcer:
LOCATED OVER BONY PROMINENCE
PRESSURE INJURY
Lecture Review
For each finding - indicate if the finding is consistent with pressure injury or venous stasis ulcer:
SURROUNDING SKIN BROWN AND EDEMATOUS
VENOUS STASIS ULCER
Lecture Review
For each finding - indicate if the finding is consistent with pressure injury or venous stasis ulcer:
SHALLOW WOUND
BOTH
PRESSURE INJURY + VENOUS STASIS ULCER
Lecture Review
For each finding - indicate if the finding is consistent with pressure injury or venous stasis ulcer:
TISSUE ISCHEMIA
PRESSURE INJURY
Lecture Review
The wound nurse confirms a stage II pressure injury.
For each potential order for tx, specify whether the order is indicated or contraindicated to include in the plan of care:
DEBRIDE WOUND
CONTRAINDICATED
Lecture Review
The wound nurse confirms a stage II pressure injury.
For each potential order for tx, specify whether the order is indicated or contraindicated to include in the plan of care:
LEAVE WOUND OPEN TO AIR
CONTRAINDICATED
Lecture Review
The wound nurse confirms a stage II pressure injury.
For each potential order for tx, specify whether the order is indicated or contraindicated to include in the plan of care:
HYDROCOLLOID DRESSING
INDICATED
Lecture Review
The wound nurse confirms a stage II pressure injury.
For each potential order for tx, specify whether the order is indicated or contraindicated to include in the plan of care:
CLEAN WITH SALINE
INDICATED
Lecture Review
The wound nurse confirms a stage II pressure injury.
For each potential order for tx, specify whether the order is indicated or contraindicated to include in the plan of care:
START IV ABX
CONTRAINDICATED
Lecture Review
The nurse receives wound care orders.
What 3 actions should the nurse teach the family about wound care?
* Wash hands prior to performing the dressing change
* Massage the heel each evening to promote blood flow
* Monitor for signs of infection
* Elevate heels while in bed
* Eat a diet high in complex carbs
* Apply a cold pack to the wound if swelling occurs
- Wash hands prior to dressing change
- Monitor for signs of infection
- Elevate heels when in bed
Lecture Review
The nurse cares for a 19-year-old wheelchair bound male [paraplegia secondary to spinal cord injury] who has come in to the clinic with his mother for a routine checkup.
From the list of choices, indicate the condition that the client is MOST LIKELY experiencing:
* Dermatitis
* Venous stasis ulcer
* Pressure injury
* Psoriasis
Pressure injury
Lecture Review
The nurse cares for a 19-year-old wheelchair bound male [paraplegia secondary to spinal cord injury] who has come in to the clinic with his mother for a routine checkup.
From the list of choices, indicate the actions that the nurse should take to address the pressure injury:
* Elevate heels
* Administer Vitamin A topically
* Perform wound care
* Administer antihistamiine
* Administer compression tx
ELEVATE HEELS
PERFORM WOUND CARE
Lecture Review
The nurse cares for a 19-year-old wheelchair bound male [paraplegia secondary to spinal cord injury] who has come in to the clinic with his mother for a routine checkup.
From the list of choices, indicate the parameters that the nurse should monitor to assess the client’s progress:
* Extent of scaling of lesions
* Signs of infection
* Distribution of rash
* Lower extremity edema
* Depth of wound
SIGNS OF INFECTION
DEPTH OF WOUND
Quiz
A nurse is caring for a client with risk for aspiration. Which of the following may indicate that the client has aspirated during an assisted feed? [Select all that apply]
* *Coughing a lot during the meal and after
* Change in voice
* SpO2 of 95%
* Shortness of breath
* Cyanosis
* Clubbing of fingers
* Drooling**
COUGHING ALOT DURING THE MEAL AND AFTER
CHANGE IN VOICE
SHORTNESS OF BREATH
CYANOSIS
DROOLING
Quiz
A nurse is admitting a client who has a virus causing nausea, vomiting, and severe diarrhea x 3 days. The patient is being admitted for supportive care including fluid replacement therapy. Which of the following findings would be expected for clients experiencing dehydration? [Select all that apply]
* Dark urine
* Low BP
* High BP
* Fatigue
* Dry mucous membranes
* Fluid overload
* Distended neck veins
DARK URINE
LOW BLOOD PRESSURE [HYPOTENSION]
FATIGUE
DRY MUCOUS MEMBRANES
PATIENT COULD ALSO PRESENT WITH TACHYCARDIA = FAST HR
Quiz
A nurse is conducting an intake interview and assessment for a new patient at a GI clinic. As part of the assessment, the nurse gathers various anthropometric measurements related to the GI system. Which of the following may be included as part of those measurements? [Select all that apply]
* BMI
* Bowel sounds
* Waist circumference
* Head circumference
BMI
WAIST CIRCUMFERENCE
Quiz
A client who is newly post op calls the surgery outpatient office to speak to a nurse about constipation and feeling bloated. Which of the following should the nurse suggest to the patient to help relieve constipation? [Select all that apply]
* Increasing fiber intake
* Increasing fluid intake
* Decreasing fiber intake
* Limiting mobility
* Only taking pain medication when necessary
INCREASING FIBER INTAKE
INCREASING FLUID INTAKE
ONLY TAKING PAIN RX/MEDS PRN
Quiz
A nurse is working with a client who is experiencing urinary and bowel incontinence. The nurse is concerned about the client’s skin integrity. What is the most appropriate intervention the nurse can use to protect the client’s skin from irritation, maceration, or breakdown?
* Utilize a barrier cream after all peri care
* Insert an indwelling foley catheter
* Apply friction when drying the skin after peri care
* Use soap to clean the client’s skin
UTILIZE A BARRIER CREAM AFTER ALL PERI CARE
Quiz
A nurse is educating a client on how to store urine for a 24 hour urine specimen collection. Which of the following statements indicates that the patient understands the instructions?
* “I will plan to store the collected specimens in the fridge unless otherwise indicated”
* “I will add urine from the first void of the day into the collection”
* “I will not add the last voided specimen”
* “I will store the collected specimens in a dark area such as the cabinet under the kitchen sink”
“I WILL PLAN TO STORE THE COLLECTED SPECIMENS IN THE FRIDGE UNLESS OTHERWISE INDICATED”
Quiz
A nurse is caring for a client with a vagina who has urinary incontinence. The client is appropriate for use of an external cath device such as a PureWick. Which of the following is the best action by the nurse when setting up this device?
* Connect the cath tubing to wall suction
* Insert the device into the client’s urethra
* Attach the cath tubing to a leg drainage bag
* Explain tha this can also be used for clients with diarrhea
CONNECT THE CATH TUBING TO WALL SUCTION
Quiz
A nurse is planning to insert a NG tube for a client who needs bowel rest. Which of the following is the most important for the nurse to perform prior to inserting the NG tube?
* Measure the length of the tube to be inserted
* Aspirate GI content to assess pH
* Obtain x-ray for verification
* Determine date of last bowel movement
MEASURE THE LENGTH OF THE TUBE TO BE INSERTED
Quiz
A nurse is educating a client who is to go home with orders for intermittent straight cathing q 4-6 hours. Which of the following statements by the client indicates a need for further teaching?
* “I am really not looking forward to have this tube in my body all of the time. I am afraid it will get caught on something as I walk around”
* “I will perform hand hygiene prior to cathing”
* “I will perfom peri care prior to cathing”
* “After inserting the cath, I will allow allow urine in my bladder to drain out”
“I AM REALLY NOT LOOKING FORWARD TO HAVE THIS TUBE IN MY BODY ALL OF THE TIME. I AM AFRAID IT WILL GET CAUGHT ON SOMETHING AS I WALK AROUND”
Quiz
A new nurse is orienting to a surgical office. The nurse is planning care for a client who has a penrose drain. Which of the following statements by the nurse indicates understanding of how to care for a penrose drain?
* “I will apply a perforated dry gauze around the drain”
* “I will gently milk the tubing to clear any clots”
* “I will empty the drain when it is 1/3 full”
* “I will connect the drain to suction”
“I WILL APPLY A PERFORATED DRY GAUZE AROUND THE DRAIN”
Quiz
Match the pressure injury stage with the wound description:
Skin Intact, localized erythema which is non-blanchable
STAGE 1
Quiz
Match the pressure injury stage with the wound description:
Partial thickness loss, exposed dermis. Wound bed visible OR may have intact/ruptured blister (serum-filled)
STAGE 2
Quiz
Match the pressure injury stage with the wound description:
Full thickness loss, adipose tissue visible, may have slough/eschar, wound bed is visible
STAGE 3
Quiz
Match the pressure injury stage with the wound description:
Full thickness loss, muscle, tendon, bone, or fascia visible
STAGE 4
Quiz
Match the pressure injury stage with the wound description:
Wound bed covered with slough or eschar, full extent of tissue loss/damage not visible
UNSTAGEABLE
Quiz
Match the pressure injury stage with the wound description:
Intact or nonintact skin, localized maroon, deep red, or purple discoloration (or dark fluid/blood filled blister)
DEEP TISSUE INJURY
Quiz
A nurse is planning to give a client a bolus feed via NG tube. Which of the following safety measures should the nurse take before, during, or after the procedure? [Select all that apply]
* Ensure the HOB is at least 30 degrees
* Assist the client into supine position after feed is complete
* Check GRV before feed
* Flush tubing before and after administering enteral feeding
* Add all medications to the clients feed
ENSURE THE HOB IS AT LEAST 30 DEGREES
CHECK GRV BEFORE FEED
FLUSH TUBING BEFORE AND AFTER ADMINISTERING ENTERAL FEED
Quiz
A new nurse is preparing to perform wound care for a client in the home setting. Using proper technique to avoid contamination, which of the following is the most appropriate action by the nurse?
* Cleanse wound from least contaminated to most contaminated area
* Cleanse wound from most contaminated to least contaminated area
* Irrigate wound holding a piston syringe less than 1 inch above the wound
* Irrigate wound with the most minimal amount of irrigation fluid, runoff should never turn clear
CLEANSE THE WOUND FROM LEAST CONTAMINATED AREA TO THE MOST CONTAMINATED AREA
CLEANEST –> DIRTIEST
Quiz
A nurse is caring for a client with incontinence. What are some strategies the nurse can support to promote urinary elimination (in general)? [Select all that apply]
* Promoting fluid intake
* Strength pelvic and abdominal muscle tone
* Maintaining a voiding schedule
* Holding urine as long as possible
* Assist client to void in usual voiding position (i.e.: sitting, standing…)
PROMOTING FLUID INTAKE
STRENGTHEN PELVIC AND ABDOMINAL MUSCLE TONE
MAINTAING A VOIDING SCHEDULE
ASSIST CLIENT TO VOID IN USUAL VOIDING POSITION [ie sitting, standing…]
Quiz
Which of the following is not an appropriate indication for inserting a urinary catheter ?
* A patient who is confused and has fallen twice trying to get out of bed to void
* A patient who is on strict I & Os in the ICU
* A patient who has not voided in 8 hours, feels “fullness” with bladder scan of 650 mL
* A patient currently intraoperative for a 7+ hour procedure
A PATIENT WHO IS CONFUSED AND HAS FALLEN TWICE TRYING TO GET OUT OF BED TO VOID
Quiz
A nurse is working in a long term care facility and caring for a client with a history of CVA who has dysphagia and is ordered a pureed diet with honey thick liquids. When entering the room, you see a tray with a cheeseburger, french fries, and a soda. What is the next best action ?
* Remove the tray
* Cut the food into very small pieces for the client
* Reassess if the client can tolerate what is on the plate
* Ask the client what they would like to eat
REMOVE THE TRAY
Quiz
A nurse is developing a plan of care for a client who has limited mobility, is confused and incontinent of bladder. What nursing interventions should be included to prevent development of a pressure injury? [Select all that apply]
* Keep skin clean and dry
* Turn and reposition q 4 hours
* Restrict fluid intake
* Massage bony prominences
* Perform frequent skin assessments and Braden scale scoring
* Optimize nutrition plan to ensure adequate nutrient intake
* Utilize supportive tools to off load pressure such as wedges, pillows, heel protector boots, etc.
KEEP SKIN CLEAN AND DRY
PERFORM FREQUENT SKIN ASSESSMENTS AND BRADEN SCALE SCORING
OPTIMIZE NUTRITION PLAN TO ENSURE ADEQUATE NUTRIENT INTAKE
UTILIZE SUPPORTIVE TOOLS TO OFF-LOAD PRESSURE SUCH AS WEDGES, PILLOWS, HEEL PROTECTOR BOOTS, ETC…
