Clinical skills week 6

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The nurse has delegated to nursing assistive personnel (NAP) the skill of assisting with a bedpan for a patient who has had discomfort when walking to the bathroom. Which statement made by the NAP requires the nurse’s follow-up?

“Do you still need a stool sample for the lab?”

“If I can get someone to help, I’ll walk her to the bathroom.” (correct)

“The patient reports that moving is uncomfortable for her. Has she had pain medication recently?”

“The patient told me that she’s had problems with hemorrhoids in the past.”

A patient with a nasogastric tube, an intravenous infusion line, and an indwelling urinary catheter needs to be placed on the bedpan. Which action would the nurse take first to ensure the patient’s safety?

Close the bedside curtain.

Raise the side rail on the side opposite that on which the nurse is working.

Obtain help to place the patient on the bedpan. (correct)

Raise the bed to a comfortable working height.

A dependent, confused patient is being given a bedpan. How can the nurse best ensure the patient’s safety?

Respond promptly to the call light.

Raise the side rails on the bed before leaving the room. (correct)

Slide one hand under the patient’s sacrum to help the patient lift off the bedpan.

Check in on the patient every 5 minutes until the bedpan can be removed.

The nurse is assisting with a bedpan for a patient who had knee surgery 24 hours ago. What is the best way for the nurse to maximize comfort while the patient uses the bedpan?

Elevate the head of the bed to between 30 and 60 degrees. Signup and view all the answers

After assisting with a bedpan, the nurse notes that the patient’s stool is streaked with bright-red blood. What would the nurse do first?

Ask if the patient has a history of hemorrhoids. Signup and view all the answers

A patient with male genitalia on bed rest is permitted to stand to use the urinal. Which action would the nurse take to ensure his safety before helping the patient to a standing position?

Determine his risk for orthostatic hypotension Signup and view all the answers

The nurse is delegating to nursing assistive personnel (NAP) the task of assisting with a urinal. The nurse specifies to NAP that the urinal is to be used in bed, not in a standing position, for which patient?

Patient with complete left-sided paralysis caused by a stroke Signup and view all the answers

Why would the nurse assess a patient’s abdomen before helping with the use of a urinal?

To assess for bladder distention Signup and view all the answers

The nurse is assisting a patient with the placement of a urinal. The patient tells the nurse, “I’ll call you when I’m done.” What is the nurse’s best response?

“Fine. Recap the urinal, hang it on your side rail, and use your call light to let me know you’re finished.” Signup and view all the answers

Which action promotes infection control when assisting a patient with a urinal?

Applying gloves before emptying and cleaning the patient’s urinal Signup and view all the answers

Which action would the nurse take to reduce the risk for a catheter-associated urinary tract infection (CAUTI) in a patient with an indwelling urinary catheter?

Use the smallest-size catheter possible. Signup and view all the answers

Which action(s) would minimize the patient’s risk for injury during insertion of an indwelling urinary catheter?

Assessing the patient for allergies related to latex, antiseptic, tape, and/or iodine-based substances Signup and view all the answers

Which statement best illustrates the nurse’s understanding of the role of nursing assistive personnel (NAP) when inserting an indwelling urinary catheter in a female patient?

“Please direct the light to better illuminate the patient’s perineal area.” Signup and view all the answers

The nurse has completed the initial inspection of the patient’s perineum and is preparing to insert an indwelling urinary catheter. Which action would the nurse complete next?

Remove soiled gloves, and perform hand hygiene. Signup and view all the answers

A female patient placed in the dorsal recumbent position for the insertion of an indwelling urinary catheter tells the nurse that she “doesn’t feel comfortable in this position” and that her “back really hurts.” What is the nurse’s best response?

Reposition the patient in a side-lying position, with her upper leg flexed at the knee and hip. Signup and view all the answers

What is the best reason for the nurse to instruct a male patient to take slow, deep breaths during insertion of an indwelling urinary catheter?

To promote relaxation Signup and view all the answers

When preparing to insert an indwelling urinary catheter in a male patient, it is important for the nurse to do what?

Lubricate the first 5 to 7 inches of the catheter. Signup and view all the answers

Which observation indicates that instruction given to nursing assistive personnel (NAP) in caring for a patient with an indwelling urinary catheter has been effective?

The excess catheter tubing has been coiled beside the patient’s inner thigh. Signup and view all the answers

Which action will the nurse implement to reduce the risk of catheter-associated urinary tract infection (CAUTI) in a male patient with an indwelling urinary catheter?

Clean the urinary meatus daily. Signup and view all the answers

While setting up the sterile field in preparation for inserting an indwelling urinary catheter, a male patient is incontinent of urine over most of the supplies. What action would the nurse take to reduce the patient’s risk for infection?

Replace all contaminated supplies, and begin the process again. Signup and view all the answers

When preparing to discharge a patient who had an indwelling urinary catheter removed 24 hours ago, the nurse would offer patient education regarding which common complication?

Urinary tract infection (UTI) Signup and view all the answers

Which action would best minimize a patient’s risk for infection during removal of an indwelling urinary catheter?

The nurse or nursing assistive personnel (NAP) removing the catheter must employ clean technique. Signup and view all the answers

Which statement might the nurse make to nursing assistive personnel (NAP) caring for a patient who has just had an indwelling urinary catheter removed?

“Tell me when and how much the patient first voids.” Signup and view all the answers

Which nursing action minimizes a patient’s risk for injury during removal of an indwelling urinary catheter?

Checking the documentation for the volume of fluid used to inflate the balloon Signup and view all the answers

Which is not an expected outcome on a first voiding after catheter removal?

Fever and back pain Signup and view all the answers

The nurse is delegating to nursing assistive personnel (NAP) the perineal care of a female patient who is totally dependent and confined to bed. Which statement by the NAP requires the nurse's follow-up?

"I'll be sure to use hot, soapy water, since she has been incontinent." Signup and view all the answers

The nurse is preparing to provide perineal care for a female patient who is on bed rest. Which patient position should the nurse use for this care?

Dorsal recumbent Signup and view all the answers

As the nurse is preparing to provide perineal care to a female patient with limited mobility, the patient says, "I can do that myself." Which action would be the priority?

Assess the patient's ability to perform proper perineal care. Signup and view all the answers

How can the nurse promote infection control while providing perineal care for a female patient who has a catheter?

By cleansing the patient's labia from the pubic area toward the rectum. Signup and view all the answers

The nurse is delegating a female patient's perineal care to nursing assistive personnel (NAP). Which instruction would the nurse give to ensure the NAP's safety while performing this care?

Wear clean gloves. Signup and view all the answers

Which of the following interventions directly related to patient safety must the nurse consider when providing perineal care to an elderly male patient with a catheter?

Wear clean gloves during care. Signup and view all the answers

The nurse observes the nursing assistive personnel (NAP) providing perineal care to a male patient. Which observation of care requires the nurse's follow-up?

Reserving the cleansing of the tip of the penis as the final step in perineal care. Signup and view all the answers

A male patient receiving perineal care tells the nurse "It has started to hurt a little down there." What is the nurse's best response?

"When did you start experiencing the pain?" Signup and view all the answers

The nurse has delegated a male patient's perineal care to the nursing assistive personnel (NAP). Which statement made by the NAP requires the nurse's follow-up?

"I will be sure to use hot, soapy water to be sure he's clean." Signup and view all the answers

What is the primary reason for performing perineal care on a male patient with incontinence?

To reduce the risk of skin breakdown in the patient's genital and perineal area Signup and view all the answers

What is the purpose of a condom catheter?

To collect urine for an incontinent man Signup and view all the answers

What is the correct method for applying a condom catheter?

Roll the condom onto the penis, leaving 1 inch between the penis and the end of the catheter Signup and view all the answers

How often should a condom catheter be changed?

Once a day after perineal care Signup and view all the answers

A person has a condom catheter that must be secured with elastic tape. How should you apply the tape?

In a spiral pattern Signup and view all the answers

After connecting the condom catheter to the drainage tubing, what should you do with the excess tubing?

Coil and secure it on the bed Signup and view all the answers

After bacteria are cultured from a midstream urine specimen, what is accomplished by sensitivity testing?

Determines which antibiotic agent is most effective in killing the bacteria Signup and view all the answers

What can the nurse do to help ensure an accurate result when collecting a midstream urine sample for a patient who is menstruating?

Make a note on the lab slip that the patient is menstruating. Signup and view all the answers

Which statement might the nurse make to nursing assistive personnel (NAP) assigned to collect a midstream urine specimen from a patient with signs of a urinary tract infection?

“Be sure to maintain aseptic technique.” Signup and view all the answers

Which statement might the nurse make to nursing assistive personnel (NAP) in order to help ensure reliable results of culture and sensitivity testing of a midstream urine specimen?

“Please get the specimen to the lab immediately.” Signup and view all the answers

What is the most important action the nurse can take to ensure that a midstream urine specimen does not become contaminated?

Ensure that the patient’s perineum has been cleansed before the specimen is obtained. Signup and view all the answers

During intermittent open bladder irrigation, a patient complains of pain. Which action would the nurse take first?

Examine the drainage tubing for clots, sediment, and kinks. Signup and view all the answers

Which action would the nurse take to minimize a patient’s risk for injury during urinary catheter irrigation?

Use slow, even pressure when injecting the irrigating fluid. Signup and view all the answers

Which instruction might the nurse give to nursing assistive personnel (NAP) helping to care for a patient receiving bladder irrigation?

“Measure and report the patient’s temperature to me every 4 hours.” Signup and view all the answers

Which action is most important in reducing the risk for infection in a patient receiving open intermittent irrigation of a urinary catheter?

Cleaning the end of the drainage tubing with an antiseptic wipe before reconnecting it to the catheter Signup and view all the answers

Which action would the nurse take to manage continuous urinary catheter irrigation for a patient whose urine is bright red and contains clots?

Increase the irrigation drip rate. Signup and view all the answers

Why does the nurse need to keep the urine sterile while obtaining a sample from an indwelling urinary catheter?

Sterile technique ensures that microorganisms in the specimen are from the urine, and not the result of contamination. Signup and view all the answers

Which action will ensure that a sterile urine specimen is handled properly in order to help obtain reliable results?

Having someone take the specimen to the lab immediately Signup and view all the answers

Which statement might the nurse make to nursing assistive personnel (NAP) before delegating the collection of a routine urine sample from a patient with an indwelling urinary catheter?

“Let me know if the urine contains blood or sediment, or appears cloudy.” Signup and view all the answers

Which measure may be taken to minimize the staff’s risk for infection from a urine specimen?

Firmly securing the lid of the urine specimen container Signup and view all the answers

When collecting a urine specimen from an indwelling urinary catheter, which action is most likely to ensure that sufficient urine is collected?

Clamping the catheter tubing for 15 minutes before collection Signup and view all the answers

While performing an intermittent straight urinary catheterization of a female patient, the nurse inadvertently inserts the catheter into the patient’s vagina. Which action would the nurse take next?

Keep the catheter in place, and begin again with a new sterile catheter. Signup and view all the answers

While attempting to perform a straight catheterization for a male patient, the nurse advances the catheter 3 to 4 inches into the meatus but observes no urine flow. Which action would the nurse take at this time?

Continue to advance the catheter until 5 to 7 inches of the catheter tube has been introduced into the urethra. Signup and view all the answers

The nurse instructs nursing assistive personnel (NAP) regarding proper technique for intermittent straight catheterization of a male patient. Which statement made by NAP indicates that the instruction was effective?

“I’ll help keep his legs away from the sterile field.” Signup and view all the answers

Why does the nurse cleanse a female patient’s perineum before inserting an intermittent urinary catheter?

To reduce the patient’s risk of urinary tract infection Signup and view all the answers

The nurse has completed an intermittent straight urinary catheterization of a female patient. Which action would the nurse delegate to nursing assistive personnel (NAP)?

Measure and empty the urine. Signup and view all the answers

Which action would the nurse take to ensure the safety of an older adult patient who has received an enema?

Provide assistance to the bathroom for expulsion of fluid and stool. Signup and view all the answers

The nurse is preparing to administer an enema. How can the nurse best facilitate insertion of the rectal tube?

Lubricate the first 6.5 to 7.5 cm (2.5 to 3 inches) of the tip of the tube. Signup and view all the answers

The nurse is delegating to nursing assistive personnel (NAP) the administration of an enema for an older adult patient who is recovering from a stroke. The enema order reads, “Enemas until clear.” Which statement made by NAP requires the nurse to follow-up?

“It may take three or four enemas to achieve a clear return.” Signup and view all the answers

The nurse has delegated administration of a standard enema for a 72-year-old patient with constipation. Which statement made by nursing assistive personnel (NAP) requires the nurse to follow-up?

“I’ll instill the solution and then check in on my other patients until I get the call signal.” Signup and view all the answers

Which action would the nurse take to reduce the risk of infection among patients and staff when administering an enema to an older adult patient with dementia?

Perform hand hygiene before donning gloves. Signup and view all the answers

What is the correct order for abdominal assessment?

Inspection, auscultation, percussion, palpation Signup and view all the answers

How often should normal bowel sounds be heard in each quadrant of the abdomen?

5–35 times per minute Signup and view all the answers

Which of the following is an important part of performing an abdominal assessment?

Explaining each step of the assessment to the patient Signup and view all the answers

What should you do if a patient is ticklish when you are palpating the abdomen?

Place your hand over the patient’s hand during palpation. Signup and view all the answers

Moderate and deep palpation of the abdomen:

All of the above Signup and view all the answers

What is the initial step in preparing a fecal occult blood test?

Determine the patient’s ability to help obtain a sample. Signup and view all the answers

The nurse has delegated to nursing assistive personnel (NAP) the task of performing fecal occult blood tests on the stool of a patient with a history of positive results. Which instruction is most relevant to performing this test in this particular patient?

“Save the stool sample so that I can retest it if it is positive.” Signup and view all the answers

Which instruction to nursing assistive personnel (NAP) is most relevant to the proper performance of a fecal occult blood test using a Hemoccult slide?

“Remember to take samples from two different areas of the specimen.” Signup and view all the answers

Which statement indicates proper interpretation of the results of a positive fecal occult blood test?

“Because it was positive, the patient must be asked when he or she last ate red meat.” Signup and view all the answers

Which of the following nursing actions addresses the risk for infection related to fecal occult blood testing?

Wearing clean gloves while testing Signup and view all the answers