Module 5 Exam Mrs. Murray Flashcards
When putting a hot or cold compress on a patient, how long should you leave it on? A. 20 mins B. 30 mins C. 15 mins. D. 1 hour
C. 15 mins.
This patient position is used during episodes of respiratory distress when inserting a nasogastric tube, and during the oral intake with feeding/aspiration precautions. A. Semi-fowlers B. Supine C. Sims D. High-Fowlers
D. High-Fowlers
A nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the following complications is the greatest risk to the client? A. Decreased subcutaneous fat B. Muscle atrophy C. Pressure injury D. Fecal impaction
C. Pressure injury
A nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development? Select all that apply.
A. Instruct the client not to perform the Valsalva maneuver.
B. Apply elastic stockings.
C. Review laboratory values for total protein level.
D. Place pillows under the client’s knees and lower extremities.
E. Assist the client to change positions often.
B. Apply elastic stockings
E. Assist the client to change positions often.
A nurse is planning care of a client who is on bed rest. Which of the following interventions should the nurse plan to implement?
A. Encourage the client to perform antiembolic exercises every 2 hrs.
B. Instruct the client to cough and deep breathe every 4 hours.
C. Restrict the client’s fluid intake
D. Reposition the client every 4 hr.
A. Encourage the client to perform antiembolic exercises every 2 hrs.
A nurse is evaluating a client’s understanding of the use of sequential compression device. Which of the following client statements indicates client understanding?
A. “This device will keep me from getting sores on my skin.”
B. “This device will keep the blood pumping through my leg.”
C. “With this device on, my leg muscles won’t get weak.”
D. “This device is going to keep my joints in good shape.”
B. “This device will keep the blood pumping through my leg.”
A nurse is instructing a client, who has an injury of the left lower extremity, about the use of a cane. Which of the following instructions should the nurse include? Select all that apply.
A. Hold the cane on the right side.
B. Keep two points of support on the floor.
C. Place the cane 38 cm in front of the feet before advancing.
D. After advancing the cane, move the weaker leg forward
E. Advance the stringer leg so that it aligns evenly on the cane.
A,B, D
A drop in ____ may occur if a heat compress is applied in a large body area.
Blood pressure
When applying a heat or cold compress, what should you put in between the skin and the compress?
A barrier, like a towel or plastic bag!
A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should be included when explaining the procedure to the client?
A. Eating more protein is optimal prior to testing.
B. One stool specimen is sufficient for testing
C. A red color change indicates a positive test
D. The specimen cannot be contaminated with urine
D. The specimen cannot be contaminated with urine
A nurse is providing dietary teaching for a client who reports constipation. Which of the following foods should the nurse recommend? A. Macaroni and cheese B. One medium apple with skin C. One cup of plain yogurt D. Roast chicken and white rice
B. One medium apple with skin
A nurse is assessing a client who has had diarrhea for 4 days. Which of the following findings should the nurse expect? Select all that apply. A. Bradycardia B. Hypotension C. Elevated temperature D. Poor skin turgor E. Peripheral Edema
B. Hypotension
C. Elevated temperature
D. Poor skin turgor
While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take?
A. Have the client hold their breath briefly and bear down.
B. Clamp the enema tubing
C. Remind the client that cramping is common at this time.
D. Raise the level of the enema fluid container.
B. Clam the enema tubing
A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following steps should the nurse take? Select all that apply.
A. Warm the enema solution prior to installation
B. Position the client on the left side with the right leg flexed forward.
C. Lubricate the rectal tube or nozzle
D. Slowly insert the rectal tube about 5 cm. (2 in)
E. Hang the enema container 61 cm (24 in) above the client’s anus.
A. Warm the enema solution prior to installation.
B. Position the client on the left side with the right leg flexed forward
C. Lubricate the rectal tube or nozzle.
A nurse is teaching a client who reports stress urinary incontinence. Which of the following instructions should the nurse include? Select all that apply. A. Limit total daily fluid intake B. Decrease or avoid caffeine C. Take calcium supplements D. Avoid drinking alcohol E. Use the Crede maneuver
B. Decrease or avoid caffeine
D. Avoid drinking alcohol
Rationale
B./C. - Caffeine/Alcohol is a bladder irritant and can worsen stress incontinence.
A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take?
A. Check to see whether the catheter is patent.
B. Reassure the client that it is not possible for them to urinate
C. Recatheterize the bladder with a larger-gauge catheter.
D. Collect a urine specimen for analysis
A. Check to see whether the catheter is patent.
Rationale:
A clogged or kinked catheter causes the bladder to fill and stimulates the need to urinate.
A nurse is caring for a client who has a prescription for a 24-hr urine collection. Which of the following actions should the nurse take?
A. Discard the first voiding.
B. Keep the urine in a single container at room temperature
C. Dispose of the last voiding
D. Ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container.
A. Discard the first voiding.
A nurse is reviewing factors that increase the risk of urinary tract infections (UTIs) with a client who has recurrent UTIs. Which of the following factors should the nurse include? Select all that apply.
A. Frequent sexual intercourse.
B. Lowering of testosterone levels
C. Wiping from front to back to clean the perineum
D. Location of the urethra closer to the anus
E. Frequent catheterization
A. Frequent sexual intercourse
D. Location of the urethra closer to the anus
E. Frequent catheterization
A nurse is preparing to initiate a bladder-retraining program for a client who has incontinence. Which of the following actions should the nurse take? Select all that apply.
A. Restrict the client’s intake of fluids during the day time.
B. Have the client record urination times.
C. Gradually increase the urination intervals
D. Remind the client to hold urine until the next schedule urination time.
E. Provide a sterile container for urine.
B. Have the client record urination times.
C. Gradually increase the urination intervals
D. Remind the client to hold urine until the next schedule urination time.
A nurse is caring for a client who is 2 days postoperative following an appendectomy and has type 1 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 teh following risk factors for impaired wound healing? Select all that apply. A. Extremes in age B. Chronic illness C. Low hemoglobin D. Malnutrition E. Poor wound care
B. Chronic Illness
C. Low hemoglobin
D. Malnutrition
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.
A nurse educator is reviewing the wound healing process with a group of nurses. The nurse educator 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 fracture D. Laceration sealed with adhesive E. Open burn area
A. Stage 3 pressure injury
E. Open burn area
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 snugly around the abdomen.
C. Use sterile gauze to apply gentle pressure to the exposed tissues.
D. Position the client supine with the hips and knees bent.
E. Offer the client a warm beverage. (herbal tea)
A. Cover the area with saline-soaked sterile dressings.
D. Position the client supine with the hips and knees bent.
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 the head of the bed elevated 30 degrees.
B. Massage the client’s bony prominences frequently
C. Apply cornstarch liberally to the skin after bathing
D. Have the client sit on a gel cushion when in a chair
E. Reposition the client at least every 3 hr while in bed.
A. Keep the head of the bed elevated 30 degrees.
D. Have the client sit on a gel cushion when in a chair.
A patient is diagnosed with a stage IV pressure ulcer with eschar. Which medical treatment should the nurse anticipate?
A. Heat lamp treatment three times a day
B. Application of a topical antibiotic
C. Cleansing irrigations twice daily
D. Debridement of the wound
D. Debridement of the wound
Which is the earliest nursing assessment that indicates permanent damage to tissues because of compression of soft tissue between a bony prominence and a mattress? A. Nonblanchable erythema B. Circumoral cyanosis C. Tissue necrosis D. Skin abrasion
A. Nonblanchable erythema
Which stage pressure ulcer requires the nurse to measure the extent of undermining? A. Stage I B. Stage II C. Stage III D. Unstageable
C. Stage III
A nurse is caring for a debilitated patient with nocturia. Which intervention is the priority when planning care for this patient?
A. Encourage bladder training
B. Provide assistance to the toilet q4h
C. Position a bedside toilet near the bed
D. Teach to avoid fluids after 5 pm
C. Position a bedside toilet near the bed
Which is an effective nursing intervention to prevent urinary tract infections?
A. Teach female patients to wipe from the back to the front after urinating
B. Advise patients to report burning of urination to health-care-providers
C. Instruct patients to use bath powder to absorb perineal perspiration
D. Encourage patients to drink several quarts of fluid daily
D. Encourage patients to drink several quarts of fluid daily.
A patient is wearing a wrist splint and is receiving passive ROM to prevent which complication? A. Atelectasis B. Renal calculi C. Pressure ulcers D. Joint contractures
D. Joint contractures
