Quiz 4
Ch 28 & 32
Ch 28 & 32
What step should the nurse complete immediately after suctioning a patient?
What is auscultating a patient's lungs?
The nurse is caring for a client in the ICU that has a GI illness that interferes with the client's ability to properly metabolize and absorb nutrients via the alimentary (GI) canal. Which method of nutritional support would the nurse expect the client to receive?
What is Total Parenteral Nutrition (TPN) through via Central Venous Catheter (CVC)?
The nurse is caring for a client who has terminal cancer and is having surgery to remove a piece of a tumor that is causing considerable pain. The nurse knows that this would be considered what type of surgery?
What is Palliative?
A client being seen in an urgent care clinic reports having pain on the right side of the abdomen. In which phase of illness is this client?
What is Seeking help?
When emptying a JP drain, the nurse measures 30 mL of thick yellow or green drainage with a bad odor. This drainage would be documented as _?
What is Purulent?
An expected response by the body's respiratory system when a nurse is caring for a healthy client with a high blood level of carbon dioxide.
What is an increased breathing rate?
The nurse needs to administer medication to a patient who has an NG tube connected to suction. Which action does the nurse take?
What is Leave the tube disconnected for 30 minutes after medication administration?
The nurse is caring for a pt who is complaining of lower abdominal pain and has not voided for 8 hrs after removing an indwelling catheter; there is no order for re-inserting a catheter. The nurse's FIRST priority action is to:
What is Perform a bladder scan to determine how much liquid is in the bladder?
The nurse is talking to a co-worker who made a medication error. The co-worker states "I did not make a medication error; I followed the physician's order." The nurse knows the use of a logical-sounding excuse to cover up true thoughts and feelings is a defense mechanism known as _.
What is Rationalization?
Upon assessing the client's I&O for a 24 hr period, the student nurse finds that the client's urinary output was 3200 mL. The nurse recognizes this as _?
What is Polyuria?
The nurse is caring for a client with COPD that has a low O2 saturation level of 89% on RA. The nurse applies O2 at 6L via NC. What physiological response should the nurse anticipate at this high rate of O2 administration?
What is a decreased respiratory rate and possibly stop?
Which of the following is an INTERDEPENDANT nursing intervention for a client with constipation?
What is Administer PRN stool softener as ordered by MD?
The nurse is inserting an indwelling urinary catheter. For which reason is the catheter advanced an additional 1 to 2 inches after urine begins to flow?
What is to make sure the balloon is in the bladder?
The nurse manager is discussing a job promotion to the charge nurse with one of the floor nurses. The floor nurse states, "I didn't get the promotion because you don't like me." The nurse manager remains calm as she knows that this form of mental or verbal "finger-pointing" at another for a problem is a defense mechanism known as _.
What is Projection?
Which technique should be used to perform a wet-to-damp dressing change?
What is place fluffed moist gauze inside the wound only?
The nurse is assessing the respiratory status of her client in the ICU. The client presents with a sequence of several breaths of equal depth that alternate with periods of apnea. The nurse would chart this respiratory pattern as _.
What is Biot's?
A nurse is assessing a dietary recall log for an adult patient with a history of hypertension and obesity. Which food selection best identifies a healthy food choice?
What is Green salad with olive oil dressing?
The doctor has ordered a sterile urine specimen for a client to rule out a UTI; which technique would be the BEST way for the nurse to guarantee the collection of a sterile urine sample?
What is a straight catheter?
The nurse is interviewing a client that states "I wasn't really angry; just a little upset." The nurse knows that expressing an emotion that is separated from the original feeling is utilizing defense mechanism known as _.
What is Isolation?
During a routine admission skin assessment, the nurse finds a wound over the client's coccyx that shows full-thickness loss involving damage to the epidermis, dermis, and subcutaneous tissue, but involving muscle or bone. The nurse would document this as a _.
What is Stage III pressure ulcer?
As the patient ages, he or she is more likely to suffer from changes to neurological function; what could be a neurological side effect of aging?
What is transient ischemic attack (TIA)?
How is the new ostomy stoma appliance cut, measured, and applied?
What is Cut opening of the wafer about 1/16 to 1/8 inch larger than the stoma?
The nurse is caring for a client who has a ruptured appendix and is rushed into surgery immediately. The nurse knows that the degree of urgency of this surgery is _?
What is Emergency?
When talking to a patient who is having a hard time describing a medical incident to the nurse, the nurse states "I see what you are saying, and then what happened?" The nurse is using a therapeutic communication technique that encourages initiation or elaboration of a conversation known as _.
What is Providing general leads?
While removing the staples after a total hip surgery, the nurse sees that there is a partial or complete separation of the outer layers of the wound; the nurse stops removing the staples and applies steri-strips to the affected area. The nurse would document this finding as _.
What is Wound dehiscence?