When putting a hot or cold compress on a patient, how long should you leave it on? A. 20 mins B. 30 minsC. 15 mins. D. 1 hour
This patient position is used during episodes of respiratory distress when inserting a nasogastric tube, and during the oral intake with feeding/aspiration precautions. A. Semi-fowlers B. Supine C. Sims D. High-Fowlers
A nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the following complications is the greatest risk to the client? A. Decreased subcutaneous fat B. Muscle atrophy C. Pressure injury D. Fecal impaction
A nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development? Select all that apply. A. Instruct the client not to perform the Valsalva maneuver. B. Apply elastic stockings. C. Review laboratory values for total protein level. D. Place pillows under the client's knees and lower extremities. E. Assist the client to change positions often.
B. Apply elastic stockings
A nurse is planning care of a client who is on bed rest. Which of the following interventions should the nurse plan to implement? A. Encourage the client to perform antiembolic exercises every 2 hrs. B. Instruct the client to cough and deep breathe every 4 hours. C. Restrict the client's fluid intake D. Reposition the client every 4 hr.
A. Encourage the client to perform antiembolic exercises every 2 hrs.
A nurse is evaluating a client's understanding of the use of sequential compression device. Which of the following client statements indicates client understanding?A. "This device will keep me from getting sores on my skin." B. "This device will keep the blood pumping through my leg." C. "With this device on, my leg muscles won't get weak." D. "This device is going to keep my joints in good shape."
B. "This device will keep the blood pumping through my leg."
A nurse is instructing a client, who has an injury of the left lower extremity, about the use of a cane. Which of the following instructions should the nurse include? Select all that apply. A. Hold the cane on the right side. B. Keep two points of support on the floor. C. Place the cane 38 cm in front of the feet before advancing. D. After advancing the cane, move the weaker leg forward E. Advance the stringer leg so that it aligns evenly on the cane.
A drop in ____ may occur if a heat compress is applied in a large body area.
When applying a heat or cold compress, what should you put in between the skin and the compress?
A barrier, like a towel or plastic bag!
A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should be included when explaining the procedure to the client? A. Eating more protein is optimal prior to testing. B. One stool specimen is sufficient for testing C. A red color change indicates a positive test D. The specimen cannot be contaminated with urine
D. The specimen cannot be contaminated with urine
A nurse is providing dietary teaching for a client who reports constipation. Which of the following foods should the nurse recommend? A. Macaroni and cheese B. One medium apple with skin C. One cup of plain yogurt D. Roast chicken and white rice
B. One medium apple with skin
A nurse is assessing a client who has had diarrhea for 4 days. Which of the following findings should the nurse expect? Select all that apply. A. Bradycardia B. Hypotension C. Elevated temperature D. Poor skin turgor E. Peripheral Edema
B. Hypotension C. Elevated temperature D. Poor skin turgor
While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take? A. Have the client hold their breath briefly and bear down. B. Clamp the enema tubing C. Remind the client that cramping is common at this time. D. Raise the level of the enema fluid container.
A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following steps should the nurse take? Select all that apply. A. Warm the enema solution prior to installation B. Position the client on the left side with the right leg flexed forward. C. Lubricate the rectal tube or nozzle D. Slowly insert the rectal tube about 5 cm. (2 in) E. Hang the enema container 61 cm (24 in) above the client's anus.
A. Warm the enema solution prior to installation. B. Position the client on the left side with the right leg flexed forward C. Lubricate the rectal tube or nozzle.
A nurse is teaching a client who reports stress urinary incontinence. Which of the following instructions should the nurse include? Select all that apply. A. Limit total daily fluid intakeB. Decrease or avoid caffeine C. Take calcium supplements D. Avoid drinking alcohol E. Use the Crede maneuver
B. Decrease or avoid caffeine D. Avoid drinking alcohol Rationale B./C. - Caffeine/Alcohol is a bladder irritant and can worsen stress incontinence.
A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take? A. Check to see whether the catheter is patent. B. Reassure the client that it is not possible for them to urinate C. Recatheterize the bladder with a larger-gauge catheter. D. Collect a urine specimen for analysis
A. Check to see whether the catheter is patent. Rationale: A clogged or kinked catheter causes the bladder to fill and stimulates the need to urinate.
A nurse is caring for a client who has a prescription for a 24-hr urine collection. Which of the following actions should the nurse take? A. Discard the first voiding. B. Keep the urine in a single container at room temperature C. Dispose of the last voiding D. Ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container.
A. Discard the first voiding.
A nurse is reviewing factors that increase the risk of urinary tract infections (UTIs) with a client who has recurrent UTIs. Which of the following factors should the nurse include? Select all that apply. A. Frequent sexual intercourse. B. Lowering of testosterone levels C. Wiping from front to back to clean the perineum D. Location of the urethra closer to the anus E. Frequent catheterization
A. Frequent sexual intercourse D. Location of the urethra closer to the anus E. Frequent catheterization
A nurse is preparing to initiate a bladder-retraining program for a client who has incontinence. Which of the following actions should the nurse take? Select all that apply. A. Restrict the client's intake of fluids during the day time. B. Have the client record urination times. C. Gradually increase the urination intervals D. Remind the client to hold urine until the next schedule urination time. E. Provide a sterile container for urine.
B. Have the client record urination times. C. Gradually increase the urination intervals D. Remind the client to hold urine until the next schedule urination time.
A nurse is caring for a client who is 2 days postoperative following an appendectomy and has type 1 diabetes mellitus. Their Hgb is 12 g/dL and BMI is 17.1. The incision is approximated and free of redness, with scant serous drainage on the dressing. The nurse should recognize that the client has which of teh following risk factors for impaired wound healing? Select all that apply. A. Extremes in age B. Chronic illness C. Low hemoglobin D. Malnutrition E. Poor wound care
B. Chronic Illness C. Low hemoglobin D. Malnutrition
A nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? Select all that apply. A. Increase in incisional pain. B. Fever and chills C. Reddened wound edges D. Increase in serosanguineous drainage E. Decrease in thirst
A. Increase in incisional pain. B. Fever and chills. C. Reddened wound edges.
A nurse educator is reviewing the wound healing process with a group of nurses. The nurse educator should include in the information which of the following alterations for wound healing by secondary intention? Select all that apply. A. Stage 3 pressure injury B. Sutured surgical incision C. Casted bone fracture D. Laceration sealed with adhesive E. Open burn area
A. Stage 3 pressure injury
A client who had abdominal surgery 24-hr ago suddenly reports a pulling sensation and pain in their surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following actions should the nurse take? Select all that apply. A. Cover the area with saline-soaked sterile dressings. B. Apply an abdominal binder snugly around the abdomen. C. Use sterile gauze to apply gentle pressure to the exposed tissues. D. Position the client supine with the hips and knees bent. E. Offer the client a warm beverage. (herbal tea)
A. Cover the area with saline-soaked sterile dressings.
A nurse is caring for a client who is at risk for developing pressure injury. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? Select all that apply. A. Keep the head of the bed elevated 30 degrees. B. Massage the client's bony prominences frequently C. Apply cornstarch liberally to the skin after bathing D. Have the client sit on a gel cushion when in a chair E. Reposition the client at least every 3 hr while in bed.
A. Keep the head of the bed elevated 30 degrees.
A patient is diagnosed with a stage IV pressure ulcer with eschar. Which medical treatment should the nurse anticipate? A. Heat lamp treatment three times a day B. Application of a topical antibiotic C. Cleansing irrigations twice daily D. Debridement of the wound
D. Debridement of the wound
Which is the earliest nursing assessment that indicates permanent damage to tissues because of compression of soft tissue between a bony prominence and a mattress? A. Nonblanchable erythema B. Circumoral cyanosis C. Tissue necrosis D. Skin abrasion
A. Nonblanchable erythema
Which stage pressure ulcer requires the nurse to measure the extent of undermining? A. Stage I B. Stage II C. Stage III D. Unstageable
A nurse is caring for a debilitated patient with nocturia. Which intervention is the priority when planning care for this patient? A. Encourage bladder training B. Provide assistance to the toilet q4hC. Position a bedside toilet near the bed D. Teach to avoid fluids after 5 pm
C. Position a bedside toilet near the bed
Which is an effective nursing intervention to prevent urinary tract infections? A. Teach female patients to wipe from the back to the front after urinating B. Advise patients to report burning of urination to health-care-providers C. Instruct patients to use bath powder to absorb perineal perspiration D. Encourage patients to drink several quarts of fluid daily
D. Encourage patients to drink several quarts of fluid daily.
A patient is wearing a wrist splint and is receiving passive ROM to prevent which complication? A. Atelectasis B. Renal calculi C. Pressure ulcers D. Joint contractures
Which task can be delegated to the UAP? A. Determining patients level of comfort B. Changing the patient's position C. Identifying mobility hazards D. Assessing circulation
B. Changing the patient's position
Metabolic changes in the immobile patient are likely to cause which of the following? A. Constipation B. Fluid volume overload C. Weight gain D. Bowel incontinence
Which nursing intervention would decrease the risk for DVT? A. Complete bed rest B. Incentive spirometry C. SCD hose D. Adequate hydration
Which patient condition cause the highest risk for complications of immobility? A. Pregnancy B. Quadriplegia C. Fractured femur D. Pneumonia
True or false: A patient can experience disuse atrophy within days of becoming immobile.
What is the first sign of pressure injury? A. Blister B. Broken skinC. Pain D. Inflammation
How can you prevent atelectasis from occurring in the immobile patient? A. SCD hose B. Pressure-relieving devices C. Incentive spirometer D. High protein diet
Which food is the best source of protein? A. Grilled chicken B. Frozen yogurt C. Diced fruit D. Leafy vegetables
Which food is the best source of fiber? A. Organ meats B. Eggs C. Oats D. Cheese
True or False:
A patient has hemiplegia as a result of a brain attack (cerebrovascular accident). Which complication of immobility is of most concern to the nurse? A. Contractures B. Dysuria C. Nocturia D. Constipation
A nurse is caring for a hospitalized patient who is performing active-range-of-motion exercises. Which of the following body movements should indicate to the nurse the patient has full range of motion of the shoulder? A. Adducting the arm so that it lies by the patient's side B. Flexing the shoulder by raising the arm from a side position to a 180-degree angle C. Abducting the arm to a 90-degree angle from the side of the body D. Circumducting the should in a 180-degree half circle
B. Flexing the shoulder by raising the arm from a side position to a 180-degree angle
A nurse stands facing a patient to demonstrate active range-of-motion exercises. Which of the following should the nurse do when hyperextension of the hip? A. Move the leg behind the body B. Move the leg forward and up C. Move the leg medially toward the other leg D. Turn the foot and leg away from the other leg.
A. Move the leg behind the body
A nurse is about to transfer to a chair of a patient who has a weak left leg. Which of the following actions by the nurse demonstrates correct transfer technique? A. Positioning the chair slightly behind the nurse so that the seat faces the patient's bed. B. Placing the patient's left leg in front of her right leg just prior to the transfer C. Aligning the nurse's knees with the patient's knees just before the transfer. D. Grasping the patient under the axilla to assist her to her feet
C. Aligning the nurse's knees with the patient's knees just before the transfer.
A nurse in the emergency department is caring for a patient who has a knee injury. The patient will be discharged and will be using a pair of axillary crutches for the first time. Which of the following instructions should the nurse include in the teaching? A. Lean on the crutches to support body weight when standing. B. Fully extend arms when holding onto the hand grips. C. Hold the crutches on the unaffected side when preparing to sit in a chair. D. Hold the crutches 9 to 12 inches in front of and to the side of each foot.
C. Hold the crutches on the unaffected side when preparing to sit in a chair.
As a nurse ambulates an unsteady patient, the patient becomes light-headed and begins to fall. Which of the following interventions by the nurse is appropriate in this situation? A. Wrap both arms around the patient's arms and shoulders B. Move both feet together when the patient begins to fall C. Protect the patient's extremities when lowering him to the floor D. Extend one leg and allow the patient to slide down it
D. Extend one leg and allow the patient to slide down it
A nurse is observing an assistive personnel who is using a mechanical lift with a hammock sling to transfer a patient from the bed to a chair? The nurse should intervene if the AP.... A. Places the sling under the patient from shoulders to knees B. Leaves the bed in the lowest position throughout the procedure. C. Locks the hydraulic valve before attaching the sling to the lift D. Raises the head of the bed to a sitting position just before transfer.
B. Leaves the bed in the lowest position throughout the procedure.
A nurse is performing a physical assessment on a patient and instructs the patient to stand with his feet together and arms at his sides. The purpose of positioning the patient in this manner is to test which of the following? A. Balance B. Muscle strength C. Reflexes D. Coordination
A nurse is preparing to administer the first of two large-volume cleansing enemas prescribed for a patient in preparation for a diagnostic procedure. Which of the following is an appropriate step in the procedure? A. Warm the enema solution prior to installation B. Prepare 1,500 mL of enema fluid C. Use tap water as the enema fluid D. Hand the enema container 24 inches above the anus
A. Warm the enema solution prior to installations
A nurse who is administering a return-flow enema to a patient should install 100 mL of enema fluid and then.... A. Instruct the patient to retain the fluid B. lower the container to allow the solution to flow back out C. Help the patient to the toilet or bedside commode D. Wait 5 min and install another 100 mL of fluid
B. Lower the container to allow the solution to flow back out.
A nurse is preparing an older adult patient for an enema. The nurse should assist the patient to which of the following positions? A. Prone B. Dorsal recumbent C. Right lateral with both knees at chest D. Left lateral with the right leg flexed
D. Left lateral with the right leg flexed
While a nurse is administering a cleansing enema, the patient reports abdominal cramping. Which of the following is the appropriate intervention? A. Measure the patient's vital signs B. Notify the primary care provider C. Lower the enema fluid container D. Stop the enema installation
C. Lower the enema fluid container
A patient who is postoperative is experiencing abdominal distention and is having difficulty expelling flatus. The nurse should anticipate receiving an order from the provider for which of the following types of enemas? A. Cleansing B. Return flow C. Medicated D. Oil-retention
A nurse is preparing to administer an oil-retention enema to a patient who has constipation. The nurse explains that the patient should try to retain the instilled oil for... A. as long as it takes to complete the procedure B. about 10-15 min C. until the next time he feels the urge to defecate D. at least 30 min, but preferably as long as he can
D. at least 30 min, but preferably as long as he can
What are the 5 types of enemas?
Cleansing, Return-flow, Oil-retention, carminative, and medicated.
The length of the tube for an enema depends on the patients... A. BMI B. Weight C. Age D. Vitals
What are the solutions you can use when giving an enema?
tap water, normal saline, and soapsuds solution
For infants and children, what type of enema fluid should they receive?
normal saline enemas ONLY
A _______ enema should not be repeated for fear of ____ toxicity or circulatory overload.
If a patient who is about to have a procedure, and they receive an "until clear" order, what does that mean?
You repeat the enema until the patient passes fluid that is clear of fecal matter and NO MORE than 3 enemas.
What is the purpose of a return flow enema?
You should repeat the return flow enema until the patient ________ ______ and ______ ______ is relieved.
passes flatus and abdominal distention
What is the purpose of an oil flow enema?
to lubricate the rectum and the colon which makes the feces absorb the oil which makes it easier to pass
For an oil flow enema to have the best results, you must instruct the patient to do what? A. Remain on the bedside commode B. Retain the enema for as long as possible preferably 1 to 3 hours. C. Immediately release the enema and wait 30 minutes to perform another enema
B. Retain the enema for as long as possible preferably 1 to 3 hours.
Instruct patients who self-administer enemas to use the _______ position. A. Supine B. Semi-Fowlers C. Sims D. Side-lying
If a patient has a cardiac disease or is taking cardiac or hypertensive medication, obtain a ___ ___ because the manipulation of rectal tissue stimulates the vagus nerve and sometimes causes a sudden decline in ___-___.
True or False-
You should use this is enemas fail to remove an impaction and this is the LAST resort in managing severe constipation. A. Colonoscopy B. Digital removal of stool C. Kayexalate
B. Digital removal of stool
Definition-
What does normal stool look like?
Which response indicates that the patient understands how to retain the enema before defecation? "I will try to retain the solution.... A. for 2 to 5 mins B. for 30 to 45 mins C. for 60 to 180 mins
Which of the following is used to administer enemas "until clear"? A. Tap water B. Hypertonic (fleet) enema C. Normal saline
To promote the patient's comfort during the administration of the enema solution, what other actions do you take? Select all that apply. A. Preheat the normal saline solution to lukewarm prior to administration B. Lubricate the tip of the rectal tube before inserting it into the patient's anus. C. Point the tip of the enema tube toward the patient's umbilicus while inserting it. D. Insert the tip of the tube approximately 5 to 7 inches in the rectum E. Have the patient bear down as you insert the tube and start the flow of the solution
A. Preheat the normal saline solution to lukewarm prior to administration B. Lubricate the tip of the rectal tube before inserting it into the patient's anus C. Point the tip of the enema tube toward the patient's umbilicus while inserting it.
You evaluate that the enemas have had a desired effect when you find a... A. A large amount of slightly discolored solution with no solid fecal matter B. A large amount of clear solution with several pea-sized flecks of stool C. Large formed stool in a large amount of clear solution
A. A large amount of slightly discolored solution with no solid fecal matter
You evaluate that the nursing assistant knows how to prepare the solution correctly when she states... A. "I can add castile soap to tap water but not normal saline" B. "I put the castile soap in the enema bag first, then I add 250 mL of fluid." C. "I should use about 1 tsp of soap in a liter of fluid."
C. "I should use about 1 tsp of soap in a liter of fluid."
Which action do you tell the nursing assistant to do first if the patient reports cramping? A. Place the patient on the bedpan to evacuate the enema solution immediately B. Remind the patient that cramping can occur during enema administration C. Lower the height of the solution bag to slow the installation rate.
C. Lower the height of the solution bag to slow the installation rate
When documenting an enema what should you include?
The date, time, and type of enema administered The volume and type of solution administered Outcomes (amount, consistency, and color of stool, bowel sounds, abdominal distention) How the patient tolerated the procedure Any adverse reactions or unexpected outcomes |
When a nurse is administering a cleansing enema the client reports abdominal cramping Which of the following is the appropriate intervention?
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