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

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.)

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.

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?

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

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

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?

Which action can a nurse delegate to AP?

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

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?

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.)

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.)

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

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

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.)

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.)

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

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

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

Which nursing intervention decreases the risk for CAUTI?

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?

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

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?

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

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

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.)

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?

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

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?

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

Match the pressure injury stages with the correct definition.

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.)

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

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

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.)

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

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

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