The nurse is preparing a male client who has an indwelling catheter and an IV
infusion to ambulate from the bed to a chair for the first time following
... [Show More] abdominal
surgery. What action(s) should the nurse implement prior to assisting the client to
the chair? (Select all that apply.)
A) Pre-medicate the client with an analgesic
B) Inform the client of the plan for moving to the chair
C) Obtain and place a portable commode by the bed.
D) Ask the client to push the IV pole to the chair.
E) Clamp the indwelling catheter.
F) Assess the client's blood pressure. - A,B,D,F
Pre-medicating the client with an analgesic (A) reduces the client's pain during
mobilization and maximizes compliance. To ensure the client's cooperation and
promote independence, the nurse should inform the client about the plan for
moving to the chair (B) and encourage the client to participate by pushing the IV
pole when walking to the chair (D). The nurse should assess the client's blood
pressure (F) prior to mobilization, which can cause orthostatic hypotension. (C and
E) are not indicated.
A client is admitted with a stage four pressure ulcer that has a black, hardened
surface and a light-pink wound bed with a malodorous green drainage. Which
dressing is best for the nurse to use first?
A) Hydrogel.
B) Exudate absorber.
C) Wet to moist dressing.
D) Transparent adhesive film - C
To provide moisture and loosen the necrotic tissue, the eschar should be covered
first with wet to moist dressings (C), which are discontinued and then a hydrogel
alginate can be placed in the prepared wound bed to prevent further damage of
granulating any surrounding tissue. Although a hydrogel (A) liquefies necrotic
tissue of slough and rehydrates the wound bed, it does not address wicking the
purulent drainage from the wound. Exudate absorbers (B) provide a moist wound
surface, absorb exudate, and support debridement, but do not prepare the woundbed for proper healing. Transparent dressings (D) are used to protect against
contamination and friction while maintaining a clean moist surface.
The nurse is preparing to irrigate a client's indwelling urinary catheter using an
open technique. What action should the nurse take after applying gloves?
A) Empty the client's urinary drainage bag.
B) Draw up the irrigating solution into the syringe.
C) Secure the client's catheter to the drainage tubing.
D) Use aseptic technique to instill the irrigating solution. - B
To irrigate an indwelling urinary catheter, the nurse should first apply gloves, then
draw up the irrigating solution into the syringe (B). The syringe is then attached to
the catheter and the fluid instilled, using aseptic technique (D). Once the irrigating
solution is instilled, the client's catheter should be secured to the drainage tubing
(C). The urinary drainage bag can be emptied (A) whenever intake and output
measurement is indicated, and the instilled irrigating fluid can be subtracted from
the output at that time.
While caring for a child and mother from Cambodia, what action should the nurse
implement to accommodate the clients' cultural needs?
A) Speak initially with the oldest family member to show respect.
B) Realize that Southeast Asians may not take Western medications.
C) Ask the husband to step out during the mother's pelvic examination.
D) Tell the family that planning health care is provided in private with the client. -
A
Members of the Asian culture have high respect for others, especially those in
positions of authority. Extended family members need to be included in the nursing
care plan (A). Southeast Asians do not necessarily refuse Western medications (B).
Asians also believe that touching strangers is not acceptable, particularly health
professionals whom they have not previously known, so the husband should be
allowed to remain with his wife during the pelvic exam (C). Provided that the
presence of other family members is not harmful to the client's well-being, (D) is
not correct.
The nurse removes the dressing on a client's heel that is covering a pressure sore
one-inch in diameter and finds that there is straw-colored drainage seeping fromthe wound. What description of this finding should the nurse include in the client's
record?
A) Stage 1 pressure sore draining sero-sanguineous drainage.
B) Pressure sore at bony prominence with exudate noted.
C) One-inch pressure sore draining serous fluid.
D) Pressure sore on heel with a small amount of purulent drainage. - C
Serous drainage is clear watery plasma, so (C) provides accurate documentation
based on the information provided. Information to stage this pressure score (A) is
not provided, and sero-sanguineous drainage is pale and watery with a combination
of plasma and red cells, and may be blood-streaked. Exudate (B) is fluid such as
pus and serum. Purulent drainage (D) is thick, yellow, green, or brown indicating
the presence of dead or living organisms and white blood cells.
The charge nurse assigns a nursing procedure to a new staff nurse who has not
previously performed the procedure. What action is most important for the new
staff nurse to take?
A) Review the steps in the procedure manual.
B) Ask another nurse to assist while implementing the procedure.
C) Follow the agency's policy and procedure.
D) Refuse to perform the task that is beyond the nurse's experience. - D
According to states' nurse practice acts, it is the responsibility of the nurse to
function within the scope of competency (D), and in this case safe nursing practice
constitutes refusal to perform the procedure because of a lack of experience.
Although state mandates, agency policies, and continued education and experience
identify tasks that are within the scope of nursing practice, nurses should first
refuse to perform tasks that are beyond their proficiency, and then pursue
opportunities to enhance their competency (A, B, and C).
A male client with venous incompetence stands up and his blood pressure
subsequently drops. Which finding should the nurse identify as a compensatory
response?
A) Bradycardia.
B) Increase in pulse rate.
C) Peripheral vasodilation.
D) Increase in cardiac output. - BWhen postural hypotension occurs, the body attempts to restore arterial pressure by
stimulating the baro-receptors to increase the heart rate (B), not decrease it (A).
Peripheral vasoconstriction, not dilation (C), of the veins and arterioles occurs with
venous incompetence through the baro-receptor reflex. A decrease in cardiac
output, not an increase (D), occurs when orthostatic hypotension occurs. [Show Less]