• A nurse is performing an abdominal assessment of a client. Which of the following positions should the nurse tell the client to assume for this
... [Show More] examination?
A. Lithotomy
-incorrect: The lithotomy position is useful for gynecological examinations.
B. Lateral
-incorrect: The lateral recumbent, or side-lying position, limits access to the abdomen. This position is useful when auscultating the heart to detect murmurs.
C. Supine
-The nurse should tell the client to assume the supine position to promote relaxation of the abdominal muscles. Having the client bend the knees enhances relaxation of the stomach muscles.
D. Sims
-incorrect: The Sims’ position limits access to the abdomen. This position is useful for rectal and vaginal examinations.
• A nurse is instructing a client about collecting a 24-hour urine specimen for creatinine clearance. Which of the following statements should the nurse identify as an indication that the client understands the procedure?
A. “The next time I urinate will be the first specimen of the collection.”
-incorrect: The collection begins after the next time the client urinates.
B. “I’ll make sure to keep the collection bottle in the container of ice they gave me.”
-The urine collection must remain chilled to prevent any change in urine composition during the collection.
C. “Once the container is half full, I no longer have to add any more urine.”
-incorrect: The urine collection for creatinine clearance specifies the duration of collection, not a minimal volume of urine.
D. “It’s okay if a piece of toilet paper gets in the bottle. The lab people will remove it when they do the test.”
-incorrect: The presence of toilet tissue, menstrual blood and feces will contaminate the specimen.
• A nurse is performing a straight catherization for a female client who has urinary retention. Which of the following actions indicates the nurse is maintaining sterile technique?
A. Applying sterile gloves to open catheter package
-incorrect: The nurse should apply sterile gloves after opening the catheter package to maintain aseptic technique, as the outside of the package is not considered sterile.
B. Wiping the labia minora in an anteroposterior direction
-The nurse should wipe anteroposteriorly both the right and left labia minora with separate cotton swabs to destroy any microorganisms in the area that would contaminate the catheter.
C. Spreading the labia with the dominant hand
-incorrect: The nurse should use the nondominant hand to spread the labia and provide the optimal view of the urethral meatus. The nondominant hand is considered contaminated once the hand touches the client’s skin.
D. Using a cotton ball to wipe the right and left labia majora
-incorrect: The nurse should use a separate cotton ball to wipe the right and left labia majora to destroy any microorganisms on the skin surface that would contaminate the catheter.
• A nurse is caring for a postoperative client who has an indwelling urinary catheter for gravity drainage. The nurse notes no urine output in the past 2 hr. Which of the following actions should the nurse take first?
A. Check to determine if the catheter tubing is kinked
-The nurse should apply the least invasive priority-setting framework when caring for this client, which assigns priority to nursing interventions that are least invasive to the client, as long as those interventions do not jeopardize client safety. This approach reduces the number of organisms introduced into the body, decreasing the number of facility-acquired infections.
Hence, the first action the nurse should take is to inspect the tubing carefully, straighten any kinks, and ensure there are no dependent loops. A lack of drainage is often due to a kink in the tubing or the client lying on it.
B. Palpate the bladder
-incorrect: The nurse should obtain a prescription to irrigate the catheter to determine if the absent urine output is due to an obstruction from blood clots or sloughing of bladder tissue. However, there is another action the nurse should take first.
C. Obtain a prescription to irrigate the catheter with 0.9% sodium chloride
-incorrect: The nurse should obtain a prescription to irrigate the catheter to determine if the absent urine output is due to an obstruction from blood clots or sloughing of bladder tissue. However, there is another action the nurse should take first.
D. Encourage the client to drink more fluids
-incorrect: The nurse can encourage the client to drink more fluids or obtain a prescription to increase the IV fluid rate if fluid overload is not a problem for the client to help increase kidney profusion and filtration of urine. However, there is another action the nurse should take first.
• A nurse is cleaning a client’s wound by swabbing from the area of least contamination to an area of greater contamination. Which of the following rationales should the nurse identify for using this technique?
A. Preventing the transfer of microorganisms to the nurse
-incorrect: Wearing appropriate personal protective equipment while performing wound care helps prevent the transfer of microorganisms from the client to the nurse.
B. Keeping microorganisms from entering the wound
-Starting at the area of least contamination and working toward the area of greatest contamination prevents the spread of microorganisms within the wound.
C. Applying minimal pressure to the wound
-incorrect: The cleansing sequence does not affect the amount of pressure applied to the wound. Pressure should be gentle. However, when necrotic tissue is removed, various methods of debridement are prescribed, some of which involve additional pressure being applied to the wound.
D. Keeping excess moisture from entering the wound
-incorrect: When excess moisture poses a hazard to a wound, a drain can be used to divert fluid away from the wound.
• After assessing a client’s radial pulses, the nurse documents “radial pulses 4+ bilaterally.” The nurse should document this finding when a client’s pulses have which of the following qualities?
A. Bounding
-A pulse of 4+ is bounding and does not disappear with moderate pressure. Pulse strength ranges from absent (0) to bounding (4+).
B. Full
-incorrect: Full pulse strength is 3+
C. Variable
-incorrect: Variable typically describes the pulse’s rate or rhythm, not its strength.
D. Weak
-incorrect: A weak pulse is 1+
• A nurse is using a portable ultrasound bladder scanner to measure a client’s post-void residual volume. Which of the following actions should the nurse take?
A. Have the client urinate 20 min before the scan
-incorrect: The nurse should instruct the client to urinate 10 mins before the bladder scanning procedure. The nurse should then document the amount of urine the client passed at that time.
B. Assist the client into a semi-fowler’s position
-incorrect: For the bladder scanning procedure, the nurse should assist the client into a supine position with the head slightly elevated.
C. Position the scanner head at the symphysis pubis
-incorrect: The nurse should position the scanner head 2.5-4 cm (1-1.6 in) above the symphysis pubis.
D. Apply light pressure to the scanner head once it is in position
-The nurse should apply light pressure and hold the scanner steadily while pointing it slightly down toward the client’s bladder. [Show Less]