Unit 2

Question 1

When using an open irrigation technique for an indwelling catheter, how much irrigation fluid should be instilled?

Answer 1

30 mL

Question 2

Is is appropriate to subtract the amount of irritant used from the client’s urine output?

Answer 2

Yes

Question 3

Client reports vomiting and diarrhea for the past 3 days.  What assessment finding would be most consistent with this info?
Neck vein distention
urine specific gravity 1.010
Rapid heart rate
BP of 144/82

Answer 3

Rapid heart rate

Tachycardia is indicative of fluid volume deficit and is consistent with the clients history

Question 4

What action should be taken if a client has phlebitis and the nurse has removed the IV catheter?

Answer 4

Place a warm compress over the IV site

Question 5

A nurse is working with an Orthodox Jewish client who has just given birth to a stillborn infant. What intervention is appropriate?

Answer 5

Ask the family if there are any special rituals that they would like to follow at this time. They may feel overwhelmed to innate discussion about it.

Question 6

Is a nurse calling a client by their first and last name in a public waiting room a violation of HIPPA?

Answer 6

NO, personal identity is not confidential

Question 7

Can a nurse take home a report sheet on her team’s client?

Answer 7

No, this is a violation of HIPPA

Question 8

Client who is receiving enteral tube feeding reports shortness of breath and is cyanotic. What should you do first?

Answer 8

Turn the client to a side-lying position.This improves gastric emptying and should improve breathing