fundamentals 2 – Flashcards
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In planning care for a client with a surgical wound healing by secondary intention, the nurse can anticipate that the client will
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be at an increased susceptibility for infection.
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A client being discharged following abdominal surgery will be performing his own dressing changes at home. It is most important for the nurse to include which of the following in the discharge plan?
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Demonstration of appropriate hand hygiene
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Cardiopulmonary resuscitation (CPR) has been initiated for a client in the emergency room. The nurse understands that a critical concept related to effective cardiac (chest) compressions is the need to
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push hard and deep on the chest.
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A client is recovering from gallbladder surgery performed under general anesthesia. The nurse should encourage the client to use the incentive spirometer how many times per hour?
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four to five
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A client's provider has ordered that a sputum specimen be collected for culture and sensitivity. The nurse plans to collect this specimen
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in the morning, on arising.
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A nurse is in a public building when someone cries out, "Help! I think he's having a heart attack!" The nurse responds to the scene and finds an unconscious adult lying on the floor. Another bystander has obtained an automated external defibrillator (AED). The nurse's first action, after making certain someone has called for emergency medical services (EMS), should be to
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administer cardiac compressions.
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When ambulating a frail, older adult client, the nurse should
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use a transfer belt if the client is unsteady.
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A client is hospitalized for an infection of a surgical wound following abdominal surgery. To promote healing and fight wound infection the nurse plans to arrange to increase the client's intake of
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vitamin C and zinc.
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While changing the linen on a client's bed, the nurse should
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hold the linen away from his body and clothing.
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A nurse is performing an eye irrigation for a client who has been exposed to smoke and ash. Which of the following nursing actions should receive the highest priority during the irrigation?
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Wearing gloves during the procedure
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A client returns from surgery with two Penrose drains in place. Anticipating frequent dressing changes, what should the nurse use around the incision area?
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Montgomery straps
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A client who is postoperative following a laparotomy is reporting pain and a dry mouth. The client has morphine sulfate ordered to control the pain. Before administering the morphine sulfate prescribed for the client the nurse should first
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measure the client's vital signs.
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A nurse is caring for a client who has just had a mastectomy and has a closed wound suction device (Hemovac) in place. Which nursing action will ensure proper operation of the device?
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Collapsing the device whenever it's one half to two thirds full of air
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When a nurse makes an initial assessment of a client who is postoperative following a gastric resection, the client's nasogastric tube is not draining. The nurse's attempt to irrigate the tube with 10 mL of 0.9% sodium chloride is unsuccessful, so she determines that the tube is obstructed. Which of the following actions should the nurse take?
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Notify the surgeon.
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A nurse is preparing to insert a nasogastric tube for a client admitted with a bowel obstruction. Which of the following should the nurse do first?
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Explain the procedure to the client.
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An older adult client has been hospitalized on bed rest for 1 week. The client reports elbow pain. Which of the following is an appropriate initial action for the nurse caring for this client to take?
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EXAMINE THE ELBOWS
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A nurse is caring for a client who is receiving an intravenous infusion (IV) that has infiltrated. Which of the following would be an unexpected finding when the nurse assesses the client's infusion line and insertion site?
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The area around the injection site feels warm when touched.
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When obtaining a urine specimen for a culture and sensitivity from an indwelling catheter, the nurse should
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cleanse the entry port prior to withdrawing urine.
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A nurse is collecting a urine specimen for a client to test via urine dipstick the urine's specific gravity. The nurse knows the result will indicate the amount of
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solutes in the urine.
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A nurse is assessing a client admitted with a sudden onset of severe back pain of unknown origin. Which statement would be most effective for the nurse use to elicit further information from this client about his pain?
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"Tell me how you are feeling right now."
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The nurse is caring for an adult client who has fluid volume excess. When weighing this client, the nurse should
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weigh the client on arising.
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A nurse takes an older adult client who has dysphagia following a cerebrovascular accident (CVA) to the dining room for dinner. When assisting the client at mealtime, the nurse should
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offer the client tart or sour foods.
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A nurse is caring for a client who is postoperative following a partial colectomy. The client has a nasogastric tube set to low continuous suction. The client tells the nurse that his throat is sore and asks the nurse when the nasogastric tube will be taken out. Which of the following responses by the nurse is appropriate at this time?
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Bowel sounds and the passing of flatus through the rectum indicate the return of peristalsis. It is then safe to remove the nasogastric tube and begin the client's progression from sips of clear liquids to a regular diet.
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A nurse is caring for several clients who are receiving oxygen therapy. Which client should the nurse assess most frequently for manifestations of oxygen toxicity? The client receiving
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100% oxygen via a partial rebreathing mask.
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The mother of a toddler calls to the nurse, "Help! My baby is choking on his food." The nurse determines that the Heimlich maneuver is necessary based on which finding?
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Inability of the toddler to cry or speak
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A nurse is caring for a client who has a new prescription for tube feeding. The nurse understands that the provider prescribed tube feeding because the client
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is unable to swallow foods by mouth.
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A client returning from the surgical suite following a vaginal hysterectomy is awake and asking for something to drink. her postoperative diet prescription reads: Clear liquids; advance diet as tolerated. Which of the following is appropriate for the nurse to tell the client?
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"I am going to listen to your abdomen."
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A client is admitted for evaluation and control of hypertension. Several hours after the client's admission, the nurse discovers the client supine on the floor, unresponsive to verbal or painful stimuli. The nurse's first action at this time should be to
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establish an airway.
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A nurse is assisting a client with a meal. The client suddenly grabs at her neck with both hands and appears frightened. The appropriate nursing action is to
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ask the client if she is choking.
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A nurse has inserted an indwelling urinary catheter for a male client. Where should the nurse tape the catheter to prevent pressure on the client's urethra at the penoscrotal junction?
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Lower abdomen
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A nurse is caring for a client who is incontinent of loose stool and is reporting a painful perineum. Which of the following is the priority nursing action?
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Check the client's perineum.
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Which nursing action prevents injury to a client's eye during the administration of eye drops?
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Holding the tip of the container above the conjunctival sac
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A nurse is planning to collect a liquid stool specimen from a client for ova and parasites. Inaccurate test results may result if the nurse
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refrigerates the collected specimen.
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A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse suspects a wound infection because the drainage on the dressing is yellow and thick. The nurse identifies this type of drainage as
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purulent.
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A nurse is teaching a client with a new colostomy about how to irrigate the ostomy. The nurse realizes that the client needs further teaching when the client
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positions the irrigating solution bag 30 inches above the stoma.
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When communicating with a client who is hearing impaired the nurse should
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face the client and speak slowly.
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A client develops a fecal impaction. Before digital removal of the mass, which type of enema should the nurse give to loosen the feces?
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Oil retention
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A client recovering from an appendectomy for a ruptured appendix has a surgical wound healing by secondary intention. When changing the client's dressing, which observation should the nurse report to the client's surgeon?
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A halo of erythema on the surrounding skin
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When replacing a client's surgical dressing, the nurse should
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don clean gloves to remove the old dressing.
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A postoperative client has an indwelling urinary catheter in place to gravity drainage. The nurse notes that the client's urinary drainage bag has been empty for 2 hr. The first action the nurse should take is to
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check to see if the tubing is kinked.
