Proceedures

Question 1

The nurse observes an LPN/LVN perform a wet-to-dry dressing change on a 2-inch abdominal incision. Which of the following behaviors, if performed by the LPN/LVN, indicates an understanding of proper technique?

1. A clean cotton ball is used to cleanse from the top of the incision to the bottom of the incision using long strokes.
2. The incision is packed with sterile gauze, and then sterile saline is poured over the dressing.
3. The nurse packs wet gauze into the incision without overlapping it onto the skin.
4. The old dressing is saturated with sterile saline before it is removed.

Answer 1

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Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) should clean from the center of wound to the outside using sterile equipment
(2) dressings should be soaked before application
(3) correct—if wet dressing touches skin, it could cause skin breakdown
(4) should be removed dry so that wound debris and necrotic tissue are removed with old dressing

Question 2

The nurse cares for a postcholecystectomy client who had the T-tube removed this morning. Two hours after removal of the T-tube, the nurse notes that the 4 × 4 dressing covering the stab site is saturated with dark, greenish-yellow drainage. It is MOST appropriate for the nurse to take which of the following actions?

1. Remove the dressing, and replace it with a more absorbent dressing.
2. Collect a culture and sensitivity specimen of the drainage.
3. Observe the wound for dehiscence.
4. Reinforce the dressing with an 8 × 10 dressing.

Answer 2

Show/hide explanation
Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? No. Determine the outcome of each implementation.

(1) correct—expected that a stab wound will continue to drain until the wound seals; nurse should keep wound clean and dry
(2) drainage described is bile, which is expected; no indication of infection
(3) doesn’t usually occur
(4) reinforcing dressing might cause infection; change dressing to keep site clean and dry

Question 3

The nurse cares for a patient following an appendectomy. The patient takes a deep breath, coughs, and then winces in pain. Which of the following statements, if made by the nurse to the patient, is BEST?

1. "Take three deep breaths, hold your incision, and then cough."
2. "That was good. Do that again and soon it won't hurt as much."
3. "It won't hurt as much if you hold your incision when you cough."
4. "Take another deep breath, hold it, and then cough deeply."

Answer 3

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Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) correct—most effective way of deep breathing and coughing, dilates airway and expands lung surface area
(2) should splint incision before coughing to reduce discomfort and increase efficiency
(3) partial answer, should take three deep breaths before coughing
(4) implies coughing routine is adequate, incision needs to be splinted

Question 4

The nurse in a psychiatric emergency room cares for a client who is a victim of interpersonal violence. The INITIAL priority of the nurse is which of the following?

1. Encourage the client to verbalize feelings.
2. Assess for physical trauma.
3. Provide privacy for the client during the interview.
4. Help the client identify and mobilize resources and support systems.

Answer 4

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Strategy: Think “Maslow.”

(1) psychosocial, priority is physical injury
(2) correct—physical, victim may have physical trauma and concealed injuries; assessment is of utmost importance so that the client’s physiologic integrity is maintained
(3) psychosocial, done concurrently as the nurse is assessing for physical injury
(4) psychosocial, priority is physical injury

Question 5

A client returns to his room following a myelogram. The nursing care plan should include which of the following?

1. Encourage oral fluid intake.
2. Maintain the prone position for 12 hours.
3. Encourage the client to ambulate after the procedure.
4. Evaluate the client's distal pulses on the affected side.

Answer 5

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Strategy: Answers are a mix of assessments and implementations. Is the assessment appropriate? No. Determine the outcome of the implementations.

(1) correct—implementation; fluids should be encouraged to facilitate dye excretion and to maintain normal spinal fluid
(2) implementation; clients are not placed in the prone position
(3) implementation; bed rest is maintained for several hours after the test
(4) assessment; an extremity was not used for injection of the dye

Question 6

When assisting with a bone marrow aspiration, the nurse should take which of the following actions?

1. Drop additional sterile supplies onto a sterile tray.
2. Unwrap all sterile packs for the procedure in case they are needed.
3. Reach over the tray, and remove contaminated supplies.
4. Place the bottle of sterile liquid on the sterile field so that it does not splash.

Answer 6

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Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) correct—sterile articles should be dropped at a reasonable distance from the edge of the sterile area
(2) sterile packs should be opened only as needed
(3) never reach an unsterile arm over a sterile field
(4) outside of a bottle containing sterile liquid is not considered to be sterile

Question 7

The nurse supervises the staff caring for four clients receiving blood transfusions. Which of the four clients should the nurse see FIRST?

1. A client complaining of a headache.
2. A client vomiting.
3. A client complaining of itching.
4. A client with neck vein distention

Answer 7

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Strategy: Determine the least stable client.

(1) febrile reaction; symptoms include fever, chills, nausea, headache; treatment is to stop blood and administer aspirin
(2) correct—hemolytic reaction; most dangerous type of transfusion reaction, symptoms include nausea, vomiting, pain in lower back, hematuria; treatment is to stop blood, obtain urine specimen, and maintain blood volume and renal perfusion
(3) allergic reaction; symptoms include urticaria, pruritus, fever; treatment is to stop blood, give Benadryl, and administer oxygen
(4) circulatory overload; treatment is to stop blood, position in an upright position, and administer oxygen

Question 8

A 13-year-old male diagnosed with muscular dystrophy (MD) develops nocturia. The client wants to know about external catheters. The nurse should base the response on which of the following statements?

1. The catheter can be removed during the day.
2. External catheters are uncomfortable.
3. The catheter would drain into a bag at the bedside or on the wheelchair.
4. The external condom catheter is easy to apply.

Answer 8

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Strategy: Think about each answer choice.

(1) correct—being free from any drain bags during the day would appeal to a 13-year-old
(2) is negative
(3) would be embarrassing to a 13-year-old
(4) it would be impossible for a teen with muscular weakness to put on an external catheter

Question 9

Which of the following techniques is correct for the nurse to use when changing a large abdominal dressing on an incision with a Penrose drain?

1. Remove the dressing layers one at a time.
2. Clean the wound with Betadine solution and hydrogen peroxide.
3. Clean the drain area first.
4. If the dressing adheres to the wound, pull gently and firmly.

Answer 9

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Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) correct—to avoid dislodging drain, remove the dressing layers one at a time
(2) do not clean a wound with both Betadine solution and hydrogen peroxide
(3) cleansing of the wound is from the center outward to the edges and from the top to the bottom
(4) incorrect; may dislodge drain

Question 10

The nurse instructs a client diagnosed with a lower motor neuron disorder to perform intermittent self-catheterization at home. The nurse should include which of the following instructions?

1. Use a new, sterile catheter each time the client performs a catheterization.
2. Perform the Valsalva maneuver before doing the catheterization.
3. Perform the catheterization procedure every 8 hours.
4. Limit oral fluids to reduce the number of times a catheterization is needed.

Answer 10

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Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) should use clean (not sterile) technique, used for clients with lower motor neuron disorders resulting in flaccid bladder
(2) correct—client holds breath and bears down as if trying to defecate, or uses Credé maneuver (places hands over bladder and pushes in and down), done to try to empty bladder before catheterization
(3) usually done every 2 to 3 hours initially, and then increased to every 4 to 6 hours
(4) should encourage fluids

Question 11

A client receives total parenteral nutrition (TPN). To determine the client’s tolerance of this treatment, the nurse should assess which of the following?

1. A significant increase in pulse rate.
2. A decrease in diastolic blood pressure.
3. Temperature in excess of 98.6°F (37°C).
4. Urine output of at least 30 ml/h.

Answer 11

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Strategy: Determine how each answer choice relates to TPN.

(1) if the pulse rate increases, may indicate fluid overload
(2) if the diastolic blood pressure decreases, it might indicate shock or lack of blood volume
(3) temperature should remain within normal limits
(4) correct—if the client is being properly hydrated with hypertonic IV such as TPN, urine output needs to be at least 30 ml/h; other nursing action includes assessment of blood glucose levels

Question 12

The nurse cares for a client with type 1 diabetes. The client receives nasal oxygen at 4 L/min. The student nurse reports that the client has pulled out the nasogastric tube and is picking at the bed covers. The client’s BP is 150/90 and pulse is 90. Which of the following actions by the nurse is MOST appropriate?

1. Obtain a pulse oximetry reading.
2. Apply soft wrist restraints.
3. Reorient the client to person and place.
4. Determine the client's blood glucose level

Answer 12

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Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes.

(1) correct—assessment; symptoms indicate reduced oxygen levels
(2) implementation; must assess first to determine problem; all other interventions must be tried before using restraints
(3) implementation; must determine the cause of the behavior before implementing
(4) assessment; symptoms indicate decreased oxygen levels

Question 13

To maintain client safety, the nurse should have which of the following equipment readily available when inserting an Ewald tube?

1. Suction equipment.
2. Blood pressure cuff.
3. Levine tube.
4. Emesis basin.

Answer 13

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Strategy: Think about each answer choice.

(1) correct—Ewald tube is a large, orogastric tube designed for rapid lavage; insertion often causes gagging and vomiting, suction equipment must be immediately available to reduce the risk of aspiration
(2) not a high priority
(3) not a high priority
(4) not a high priority

Question 14

The nurse cares for clients in the emergency department of an acute care facility. Four clients have been admitted during the previous 10 minutes. Which of the following admissions should the nurse see FIRST?

1. A client complaining of chest pain that is unrelieved by nitroglycerine.
2. A client with full-thickness burns to the face.
3. A client with a fractured hip.
4. A client complaining of epigastric pain.

Answer 14

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Strategy: Think ABCs.

(1) not the highest priority; airway most important
(2) correct—face, neck, chest, or abdominal burns result in severe edema, causing airway restriction
(3) airway is most important
(4) requires further assessment; airway is a priority

Question 15

The nurse plans care for a client returning from surgery after a bowel resection with an IV of 0.9 % NaCl infusing at 100 mL/h into the left wrist. Which of the following actions, if performed by the nurse, is BEST?

1. Change the IV tubing each time a new IV solution is hung.
2. Cleanse the IV site with an alcohol swab using long strokes.
3. Limit manipulation of the cannula at the IV insertion site.
4. Adjust the drop rate to keep the total volume of IV fluids on schedule.

Answer 15

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Strategy: The topic of the question is unstated. Read the answer choices to determine the topic. “BEST” indicates that this is a priority question. All answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) unnecessary, changed every 48 to 72 h
(2) should move swab in a circular motion outward
(3) correct—will prevent dislodgment of needle
(4) should give IV at rate ordered by physician, don’t play “catch-up” with fluids

Question 16

The nurse notes that one of the staff members caring for clients has a watery discharge from the right eye and the eye appears red. Which of the following actions, if taken by the nurse, is BEST?

1. Send the staff member home.
2. Assess the staff member's compliance with standard precautions.
3. Assign the staff member only to clients with chronic diseases.
4. Reassign the staff member to clean the supply closet.

Answer 16

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Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) correct—extreme tearing, redness, foreign body sensation are symptoms of viral conjunctivitis; highly contagious; infected employees cannot work until symptoms have resolved in 3 to 7 days
(2) restrict from patient contact and the patient’s environment
(3) restrict from patient contact and the patient’s environment
(4) cannot work

Question 17

The nurse observes a student nurse check the placement of a nasogastric (NG) tube prior to administering an intermittent feeding. Which of the following actions, if performed by the student nurse, requires an intervention by the nurse?

Select all that apply.

1. The student nurse checks the pH of the contents aspirated from the NG tube.
2. The student nurse positions a stethoscope on the upper abdomen and listens as air is introduced into the NG tube.
3. The student nurse uses a large-barreled syringe to aspirate for stomach contents.
4. The student nurse flushes the NG tube with 30 ml of air before aspirating fluid.
5. The student nurse places the end of the NG tube in a cup of water and watches for bubble formation.

Answer 17

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“Requires an intervention” indicates incorrect behavior.

(1) appropriate action; if client has for at least 4 hours, pH of gastric aspirate is 1 to 4
(2) correct—air injected to lungs, pharynx or esophagus may transmit similar sound
(3) acceptable action
(4) appropriate action; enables easier aspiration of fluid
(5) correct—not considered acceptable procedure; if tube placed in lungs, may cause bubbling

Question 18

While scheduling the administration of bromocriptine (Parlodel), which nursing action has the HIGHEST priority?

1. The medication should be taken once a day for 6 weeks.
2. The medication should be taken with orange juice.
3. The medication should be taken in the morning and at bedtime.
4. The medication should be taken with meals.

Answer 18

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Strategy: Answers are implementations. Determine the outcome of each answer. Is it desired?

(1) is taken twice a day for 2 to 3 weeks
(2) unnecessary
(3) will cause GI upset unless taken with meals
(4) correct—will decrease GI upset

Question 19

The nurse in a long-term care facility reviews the nurse’s notes in a client’s chart. The nurse is MOST concerned by which of the following entries?

1. "Foley catheter draining clear urine and the pH is 6.5."
2. "The client's skin is blanched over the scapular areas."
3. "Vital signs are within normal limits."
4. "The client drinks three glasses of orange juice every day."

Answer 19

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Strategy: “MOST concerned” indicates something is wrong.

(1) appropriate charting of normal urine
(2) correct—blanching or hyperemia that does not disappear in a short time is a warning sign of pressure ulcers
(3) although the charting is not objective, blanching of the skin takes priority because it indicates a problem
(4) appropriate charting

Question 20

The nurse cares for clients in the outpatient clinic. The nurse returns to the desk and finds four phone messages. Which of the following messages should the nurse return FIRST?

1. A client with cold symptoms has an oral temperature of 103°F (39.4°C).
2. A client with stage II decubitus ulcer reports that the dressing has come off.
3. A client is nauseated and has vomited 6 times in the previous 24 hours.
4. A client complains of leg pain after walking half a mile.

Answer 20

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Strategy: Eliminate the two most stable clients. Use the ABCs to determine the most unstable client.

(1) elevated temperature indicates infection; determine the underlying cause, encourage fluids
(2) stable client
(3) correct—assess amount, character, symptoms of fluid volume deficit
(4) stable client, complaint indicates intermittent claudication

Question 21

A client has a bovine graft inserted into the left arm for hemodialysis. During the immediate postoperative period, which of the following actions, if performed by the nurse, is BEST?

1. Restart the IV above the level of the graft.
2. Take blood pressures on the right arm.
3. Elevate the left arm above the level of the heart.
4. Check the radial pulse on the left arm q4h.

Answer 21

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Strategy: Determine the outcome of each answer choice.

(1) IVs should not be started in the grafted arm
(2) correct—BP should always be taken on the opposite arm from the graft
(3) unnecessary
(4) important to assess circulation in extremity; priority is to prevent complication

Question 22

The physician orders indomethacin (Indocin) 25 mg PO bid for a client. It is MOST important for the nurse to make which of the following statements?

1. "Take this medication with food."
2. "Take this medication one hour before meals."
3. "Take this medication one hour after meals."
4. "Take this medication with orange juice.

Answer 22

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Strategy: “MOST important” indicates discrimination is required to answer the question.

(1) correct—reduces GI upset
(2) risk of GI upset
(3) should be given with food
(4) risk of GI upset

Question 23

The nurse supervises a student nurse administer a tube feeding to a client via a Levin tube. Which of the following actions, if performed by the student nurse, indicates a proper understanding of the procedure?

1. The Levin tube remains unclamped for 30 min after the feeding.
2. Sterile equipment is used to administer the feeding.
3. The amount of the feeding is varied according to the patient's tolerance.
4. The tube feeding is given at room temperature.

Answer 23

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Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) clamping tube between feedings prevents introduction of air and loss of liquid
(2) clean, not sterile, supplies are required
(3) physician will order amount of feedings; usually begin with a small amount and increases 50-100 mL until nutritional requirements met
(4) correct—minimizes intestinal cramping

Question 24

At approximately 6 PM, the nurse begins to open the nurses’ notes for the evening shift. The last entry is noted for 1 PM, and there is no signature. Which of the following responses by the nurse is MOST appropriate?

1. Leave approximately three or four lines for the day nurse to enter the day information and sign the chart.
2. Review with the client the activities after 1 PM and enter what are determined to be the activities after 1 PM.
3. Begin charting on the next line below the last entry and make a note for the day nurse to make a late entry to complete the chart.
4. Do not enter anything until the day nurse has been notified of the problem and returns to the unit to complete charting.

Answer 24

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Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) blank lines should never be left in the nurses’ notes
(2) nurse should chart only the care that s/he has administered
(3) correct—day nurse can make a “late entry” to add any additional information
(4) unnecessary

Question 25

The nurse prepares a client for a paracentesis. It is MOST important for the nurse to take which of the following actions?

1. Keep the client NPO 12 hours before the procedure.
2. Ask the client to void just before the procedure.
3. Initiate a bowel preparation program 24 hours before the procedure.
4. Place the client supine during the procedure.

Answer 25

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Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is it desired?

(1) does not need to be NPO
(2) correct—prevents puncture of bladder
(3) bowel preparation unnecessary
(4) would make it more difficult to drain fluid; patient should be positioned sitting upright at side of bed with feet supported

Question 26

The nurse is caring for a client in the ICU. Hemodynamic monitoring is accomplished by way of a Swan-Ganz catheter. The nurse is aware that this type of monitoring will provide which of the following information?

1. Measures the circulatory volume in the coronary arteries.
2. Indirectly measures the pressure in the ventricles.
3. Analyzes the adequacy of pulmonary circulation.
4. Directly measures the adequacy of carbon dioxide exchange.

Answer 26

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Strategy: Think about each answer choice.

(1) not a function of this catheter, and does not reflect hemodynamic monitoring
(2) correct—CVP readings measure the pressure in the right ventricle, the Swan-Ganz catheter measures the pulmonary artery wedge pressure, which is an indirect reading of the pressure in the left ventricle
(3) not a function of this catheter, and does not reflect hemodynamic monitoring
(4) not a function of this catheter, and does not reflect hemodynamic monitoring

Question 27

The nurse has just received report from the previous shift. Which of the following clients should the nurse see FIRST?

1. A client with chronic renal failure complaining of swollen fingers and ankle edema.
2. A client 1 day postoperative after abdominal surgery with dried blood on the abdominal dressing.
3. A client diagnosed with type 1 diabetes mellitus who states, "I have this quivering feeling in my abdomen."
4. A client on high doses of antibiotics for a resistant infection complaining of diarrhea.

Answer 27

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Strategy: Determine the least stable client.

(1) indicates peripheral edema, treatment includes fluid and sodium restrictions
(2) stable client
(3) correct—indicates hypoglycemia; symptoms include tachycardia, cold and clammy skin, weakness and pallor; check blood sugar, offer milk
(4) common sequelae of antibiotic therapy, monitor fluid and electrolytes, check for skin breakdown

Question 28

The nurse prepares a client for a herniorrhaphy. It is MOST important for the nurse to take which of the following actions 1 hour before surgery?

1. Administer an enema.
2. Confirm that the consent form has been signed.
3. Perform a preoperative shave and scrub.
4. Evaluate for food or medication allergies.

Answer 28

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Strategy: Answers are a mix of assessments and implementations. Is the assessment appropriate 1 hour before surgery? No. Determine the outcome of each implementation.

(1) should be done earlier than 1 hour before surgery
(2) correct—surgical consent should be rechecked before going to surgery
(3) should be done earlier than 1 hour before surgery
(4) assessment; should be done earlier than 1 hour before surgery

Question 29

A 10-year-old child weighing 50 lb (23.6 kg) returns from surgery for a skin graft to the left leg. The patient has an IV of D5W infusing into the left arm. The physician’s orders read: “D5W 2,000 cc/24 h.” It is MOST important for the nurse to take which of the following actions?

1. Call the physician to clarify the IV fluid order.
2. Keep accurate records of the patient's intake and output.
3. Set the controller on the IV pump to infuse at 84 gtt/min.
4. Monitor the patient for fluid and electrolyte balance.

Answer 29

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Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? No. Determine the outcome of each implementation. Is it desired?

(1) correct—implementation, amount is excessive for child and there are no electrolytes in fluid
(2) implementation, may have serious electrolyte disturbances before discrepancies are seen in I and O
(3) implementation, rate is correct for amount of fluid ordered, but amount is excessive for child and fluid is inappropriate
(4) assessment, should not administer fluids as ordered because they are inappropriate in amount and content

Question 30

The nursing team consists of an RN, two LPN/LVNs, and a nursing assistant. The RN should care for which of the following clients?

1. An infant 2 days postoperative after repair of cleft lip requiring a tube feeding.
2. A preschool child 3 days postoperative after surgical removal of Wilms' tumor requiring a bath.
3. A school-aged child diagnosed with osteomyelitis requiring a dressing change.
4. A teenager with a head injury, Glasgow coma scale is 5, requiring personal care.

Answer 30

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Strategy: RNs care for clients who require assessment, teaching, and nursing judgment.

(1) stable patient with an expected outcome, assigned to the LPN/LVN
(2) standard, unchanging procedure, assign to the nursing assistant
(3) stable patient with an expected outcome, assign to the LPN/LVN
(4) correct—Glasgow coma scale of 5 indicates coma, client requires frequent assessment

Question 31

The nurse observes a staff member enter the room of a client wearing a scrub suit. The nurse determines that the staff member is using the proper precautions if the staff member cares for which of the following clients?

1. A client diagnosed with cancer complaining of a sore mouth.
2. A client diagnosed with tuberculosis requiring administration of Rifampin.
3. A client diagnosed with rubella requiring an IM injection.
4. A client diagnosed with a draining abscess that is not covered with a dressing.

Answer 31

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Strategy: Determine what type of precautions are needed for each client.

(1) correct—indicates Candida, standard precautions required
(2) requires airborne precautions
(3) requires droplet precautions
(4) abscess with no dressing requires contact precaution

Question 32

The nurse observes the following patients in the emergency department (ED). Which of the following patients should the nurse see FIRST?

1. 8-month-old infant crying loudly with facial ecchymosis.
2. 12-year-old boy with a possible fractured ankle.
3. 34-year-old man with a distended abdomen and splenomegaly.
4. 44-year-old woman with possible whiplash from an automobile accident.

Answer 32

Show/hide explanation
Strategy: Determine the most unstable client.

(1) crying demonstrates adequate airway, not life-threatening
(2) not life-threatening
(3) correct—possibility of internal bleeding, life-threatening situation
(4) not life-threatening

Question 33

The charge nurse notes a young child is placed on droplet precautions. The charge nurse identifies that the nurse cares for which of the following clients?

1. A child with cystic fibrosis.
2. A child with tonsillitis.
3. A child with bronchitis.
4. A child with pertussis.

Answer 33

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Strategy: Think about the communicability of each disease.

(1) hereditary dysfunction of exocrine glands causing obstruction because of flow of thick mucus, standard precautions
(2) inflammation of tonsils, standard precautions
(3) inflammation of large airway, standard precautions
(4) correct—droplet precautions required, private room, maintain spatial separation of 3 feet between patient and visitors

Question 34

While performing care for an elderly patient, the nurse notices that the patient has a dry, parched mouth and tongue. The nurse should take which of the following actions?

1. Brush the patient's teeth with a hard-bristled toothbrush before meals and at bedtime.
2. Use glycerin swabs to perform mouth care every 4 hours.
3. Rinse the patient's mouth with room-temperature tap water before and after meals.
4. Use a water pick, then rinse with commercial mouthwash every 8 hours to freshen the mouth.

Answer 34

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Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) should use soft-bristled toothbrush so gums are not injured
(2) should be avoided, causes dryness of mucous membranes
(3) correct—will hydrate the mucous membranes and keep mouth clean
(4) most commercial mouthwashes contain alcohol, would dry mucous membranes

Question 35

The home care nurse instructs the spouse of a client about how to perform a wet-to-dry abdominal dressing for the client because of an infected abdominal incision. The nurse should intervene if which of the following is observed?

1. The client’s spouse wets the old dressing with sterile saline before removing it.
2. The client’s spouse covers the wound with wet, sterile 4 × 4s.
3. The client’s spouse irrigates the wound with hydrogen peroxide using a bulb syringe.
4. The client’s spouse uses Montgomery straps to secure the dressing.

Answer 35

Show/hide explanation
Strategy: “Nurse should intervene” indicates an incorrect action.

(1) correct—contraindicated, remove dry so wound debris and necrotic tissue are removed with old dressing
(2) purpose of wet-to-dry dressing is to débride incision; wetting dressing before removal defeats purpose of dressing
(3) irrigation of wound sometimes used
(4) adhesive is attached to skin and laced to secure dressing, used when frequent dressing changes are anticipated

Question 36

The nurse receives a bedside report from another nurse. The nurse giving the report begins to talk about another client. Which action by the nurse receiving the report is MOST appropriate?

1. Ask the nurse to report on this client only.
2. Ask the nurse to lower his/her voice.
3. Ask the nurse to move to another part of the room.
4. Ask the nurse to clarify which client s/he is reporting on.

Answer 36

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Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) correct—client confidentiality is being violated, nurse should intervene to protect client
(2) does not provide for client confidentiality
(3) does not provide for client confidentiality
(4) does not provide for client confidentiality

Question 37

A patient received meperidine (Demerol) 75 mg IM 2 hours ago for complaints of pain. The patient turns on the call light and tells the nurse he has to go to the bathroom. The physician ordered bathroom privileges. The nurse should take which of the following actions?

1. Obtain a bedside commode for the patient's use and provide privacy.
2. Help the patient to sit on the side of the bed before proceeding to the bathroom.
3. Provide a bedpan for the patient's use and pull the curtains.
4. Ask two nurses to assist the patient to the bathroom.

Answer 37

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Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) should ambulate patient safely to prevent hazards of immobility
(2) correct—side effects of medication include decreased BP, orthostatic hypotension, bradycardia
(3) easier for patient to use bathroom than to use bedpan
(4) an additional nurse not necessary, before ambulating should sit on side of bed to allow body to adjust to change in position

Question 38

An elderly adult is admitted to a medical unit with shortness of breath and is diagnosed with an upper respiratory infection (URI). The client is placed on droplet precautions. The nurse administers oral medications to the client. As the nurse leaves the room, the nurse should take which of the following actions?

1. Wash hands, remove the gown and mask, and throw the trash in a container outside of the room.
2. Remove the mask, wash hands, and throw the trash in a container inside the room.
3. Wash hands, remove the mask, and throw the trash in a container inside the room.
4. Remove the gown and gloves, wash hands, remove the mask, and throw the trash in a container inside the room.

Answer 38

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Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) gown unnecessary, trash should be left inside room
(2) wash hands then remove mask, so microbes aren’t transferred from hands to face
(3) correct—hands should be washed before removing mask to prevent transfer of microbes to face
(4) gown unnecessary

Question 39

A client has a subclavian triple lumen catheter used for administration of total parenteral nutrition (TPN). The physician orders all lumens be flushed with a diluted heparin solution BID. When the nurse attempts to flush the distal lumen, resistance is met. The nurse should take which of the following actions?

1. Clamp off the lumen and label it as "clotted off."
2. Gradually increase the pressure on the irrigating solution.
3. Aspirate blood from the lumen to restore patency.
4. Secure the lumen with a Luer-Lock cap and notify the physician.

Answer 39

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Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) should be reported to the physician to see if patency can be re-established before it is labeled as clotted off
(2) force should never be used to irrigate the catheter
(3) blood should not be aspirated from the catheter
(4) correct—streptokinase may be used to dissolve clot; if unsuccessful, lumen is labeled as clotted off