Ch. 45, 46, 47, 48 End of Ch. Review--Textbook

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The nurse is caring for a patient with pneumonia, who has severe malnutrition. The patient’s condition places her at risk for which of the following life-threatening complications during hospitalization? (Select all that apply.)

Heart disease

Sepsis (correct)

Hemorrhage (correct)

Skin breakdown (correct)

The nurse is preparing to perform a blood glucose monitoring test on a patient. Place the steps for performing the procedure in the correct sequence.

nstruct patient to perform hand hygiene, Check code on test strip vial. = 1 Press button on meter to confirm match codes. Perform hand hygiene and put on clean gloves. = 2 Clean patient finger with antiseptic swab. Holding lancet to finger, press release button on machine. = 3 Bringing meter to test strip, allow blood drop to wick onto test strip. Interpret results and document. = 4

The nurse is caring for a patient with dysphagia and is feeding her a pureed chicken diet. Suddenly the patient begins to choke. What is the priority nursing intervention?

Suction her mouth and throat.

Turn her on her side.

Put on oxygen at 2 L nasal cannula.

Stop feeding her. (correct)

The nurse is changing the PN tubing. What action should the nurse take to prevent an air embolus?

Have the patient turn on the left side and perform a Valsalva maneuver. Signup and view all the answers

A patient is receiving both PN and EN. When would the nurse collaborate with the health care provider and request a discontinuation of PN?

When 75% of the patient’s nutritional needs are met by the tube feedings Signup and view all the answers

A patient is receiving an enteral feeding at 65 mL/h. The GRV in 4 hours was 125 mL. What is the priority nursing intervention?

Continue the feedings; this is normal gastric residual for this feeding. Signup and view all the answers

Which action can a nurse delegate to AP?

Performing glucose monitoring every 6 hours on a stable patient Signup and view all the answers

Which statement made by the parents of a 2-month-old infant requires further education by the nurse?

“I’m going to alternate formula with whole milk, starting next month.” Signup and view all the answers

A nurse sees an AP perform the following interventions for a patient receiving continuous enteral feedings. Which action would require immediate attention by the nurse?

Placing patient supine while giving a bath Signup and view all the answers

A patient is receiving total parenteral nutrition (TPN). What are the primary interventions the nurse should follow to prevent a central line infection? (Select all that apply.)

Change the dressing using sterile technique. Signup and view all the answers

A patient is scheduled to have an intravenous pyelogram (IVP) tomorrow morning. Which nursing measures should be implemented before the test? (Select all that apply.)

Ask the patient about any allergies and reactions. Signup and view all the answers

What is a critical step when inserting an indwelling catheter into a male patient?

Advance the catheter to the bifurcation of the drainage and balloon ports. Signup and view all the answers

Which instruction should the nurse give the assistive personnel (AP) concerning a patient who has had an indwelling urinary catheter removed that day?

Report the time and amount of first voiding. Signup and view all the answers

A patient with a three-way indwelling urinary catheter and CBI complains of lower abdominal pain and distention after surgery. What should be the nurse’s initial intervention(s)? (Select all that apply.)

Assess the patency of the drainage system. Signup and view all the answers

After abdominal surgery, the patient is on the surgical unit with an indwelling urinary catheter placed. What aspects of care for this patient can be delegated to the assistive personnel (AP)? (Select all that apply.)

Assisting the nurse with patient positioning and maintaining privacy during catheter care Signup and view all the answers

What should the nurse teach a young woman with a history of UTIs about UTI prevention? (Select all that apply.)

Maintain regular bowel elimination. Signup and view all the answers

Place the following steps for insertion of an indwelling catheter in a female patient in appropriate order.

1 = Drape patient with the sterile square and fenestrated drapes. Prepare sterile field and supplies. Lubricate catheter. 2 = Cleanse urethral meatus with antiseptic solution. Insert and advance catheter. 3 = When urine appears, advance another 2.5 to 5 cm. Inflate catheter balloon. 4 = Gently pull catheter until resistance is felt. Attach drainage tubing. Signup and view all the answers

Which nursing interventions should a nurse implement when removing an indwelling urinary catheter in an adult patient? (Select all that apply.)

Allow the balloon to drain into the syringe by gravity. Signup and view all the answers

Which nursing intervention decreases the risk for CAUTI?

Hanging the urinary drainage bag below the level of the bladder Signup and view all the answers

The nurse is inserting a urinary catheter for a female patient, and after the catheter has been inserted 3 inches, no urine is returned. What should the nurse do next?

Leave the catheter there and start over with a new catheter. Signup and view all the answers

Which nursing actions does the nurse take when placing a bedpan under a patient who is immobilized? (Select all that apply.)

After positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle. Signup and view all the answers

During the administration of a warm tap-water enema, a patient starts to have cramping abdominal pain that he rates a 6 out of 10. What nursing action should the nurse take first?

Stop the instillation. Signup and view all the answers

Which instructions does the nurse include when educating a person with chronic constipation? (Select all that apply.)

Increase fiber and fluids in the diet. Signup and view all the answers

Which skills does the nurse teach a patient with a new colostomy before discharge from the health care agency? (Select all that apply.)

How to change the pouch Signup and view all the answers

A nurse is teaching a patient about the warning signs of possible colorectal cancer according to the American Cancer Society guidelines. Which statements reflect that the patient understands the teaching? (Select all that apply.)

“I need to let my doctor know if my bowel habits start to change.” Signup and view all the answers

A nurse is teaching a patient to obtain a specimen for fecal occult blood testing using fecal immunochemical testing (FIT) at home. How does the nurse instruct the patient to collect the specimen?

Collect one fecal smear from three separate bowel movements. Signup and view all the answers

What should the nurse teach family caregivers when a patient has fecal incontinence because of cognitive impairment?

Initiate a bowel or habit training program to promote continence. Signup and view all the answers

The patient states, “I have diarrhea and cramping every time I have ice cream. I am sure this is because the food is cold.” Based on this assessment data, which health problem does the nurse suspect?

Lactose intolerance Signup and view all the answers

When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch?

Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode Signup and view all the answers

Match the pressure injury stages with the correct definition.

Stage 1 = Intact skin with a localized area of non- blanchable erythema, which may ap- pear differently in darkly pigmented skin. Presence of blanchable erythema. Stage 2 = Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, and moist, and may also present as an intact or ruptured serum-filled blister. Adipose tissue (fat) and deeper tissues are not visible. Stage 3 = Full-thickness loss of skin, in which adipose tissue (fat) is visible in the ulcer, and granulation tissue and epibole (rolled wound edges) are often present. Stage 4 = Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Signup and view all the answers

After surgery the patient with a closed abdominal wound reports a sudden “pop” after coughing. When the nurse examines the surgical wound site, the sutures are open, and small bowel sections are observed at the bottom of the now-opened wound. Which are the priority nursing interventions? (Select all that apply.)

Notify the health care provider. Signup and view all the answers

Which skin-care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (Select all that apply.)

Frequent position changes Signup and view all the answers

Which of the following are measures to reduce tissue damage from shear? (Select all that apply.)

Use a transfer device (e.g., transfer board). Signup and view all the answers

Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? (Select all that apply.)

Provision of support to abdominal tissues when coughing or walking Signup and view all the answers

Medical adhesives, such as tape securing a wound dressing, cause MARSI. Which of the following interventions reduce the risk for MARSI?

Gently loosen the ends of the tape and gently pull the outer end parallel with the skin surface toward the wound. Signup and view all the answers

What is the removal of devitalized tissue from a wound called?

Debridement Signup and view all the answers

Which of the following nursing activities apply to an MDRPI? (Select all that apply.)

Choose correct size of device. Signup and view all the answers