Skills
When providing perineal care for an uncircumcised male patient, the nurse:
retracts the foreskin and then cleans the glans, being sure to replace it at the end of the procedure.
In the uncircumcised male, the foreskin covers the glans and must be retracted to adequately cleanse the secretions that accumulate under the foreskin and can lead to infection. The foreskin must be pulled down to cover the glans after cleaning or it can swell and cause pain and constriction of the glans.
The nurse would document a patient as being febrile if the patient’s temperature was over:
100.5° F
A patient with a temperature above the normal range (100.2° F) is called febrile.
What are the main functions of the skin?
Protection
Excretion
Sensation
Secretion
Tachycardia
faster than normal pulse.
The nurse caring for a patient receiving enteral feedings would assess for tolerance of the feeding by monitoring:
for abdominal distention.
Assessing the abdomen for distention helps the nurse identify the intolerance of tube feedings.
What are the main functions of the skin?
Protection
Excretion
Sensation
Secretion
The nurse caring for a 30-year-old postsurgical patient would assess that the patient is in pain as indicated by:
a pulse rate of 120 beats/min.
Pain increases the pulse rate.
Because the older adult patient lies curled up in a side lying position most of the time, the nurse, seeking to avoid a pressure ulcer, makes frequent assessments of the:
ilium.
A patient who lies in a constant side lying position puts pressure on the bony prominence of the ilium. The sacrum, heels, and scapula are at risk in a patient who lies on his or her back.
Eupnea
Normal breathing.
excessive urine output.
increased pulse rate.
dyspnea.
Providing oral care to a patient who has dentures includes what safety/infection control measures:
Placing towels in the sink BEFORE brushing the dentures
Patient is positioned in an upright position (High Fowlers)
ALWAYS wearing gloves when touching the dentures
The nurse anticipates that if the stroke volume of a patient is reduced, the pulse will be:
weaker.
A weak pulse will result if the stroke volume is reduced, because this decreases circulating volume.
Stroke volume: The amount of blood pumped by the left ventricle of the heart in one contraction.
Because of the patient’s dysphagia, the nurse recommends to the physician that the patient be placed on a Level II texture level diet, which means that the food is:
mechanically altered, moist, minced helpings.
Level II texture is a diet in which the food has been mechanically altered to moist, 1/4 inch pieces.
My sons first name?
Greg.
When caring for a patient receiving total parenteral nutrition, the nurse knows that it is essential to:
monitor the blood glucose.
Total parenteral nutrition contains a high concentration of glucose, and monitoring blood glucose every 6 to 8 hours will determine patient tolerance.
What observations should you take when performing nail care in a patient?
Observe the color of the nail beds to monitor circulation in the extremities.
The nurse is caring for a patient who had a cardiac catheterization 2 hours ago and has a pressure dressing to his left groin. In addition to taking routine vital signs, the nurse should also check the:
presence of the pedal pulse.
Pedal pulses are checked to determine whether there is any blockage in the artery following a cardiac catheterization.
A patient who is badly constipated has just received an oil retention enema. The nurse encourages this patient to try to hold the enema for at least how long before trying to have a bowel movement?
20 minutes
The oil retention enema should be retained for 20 minutes.
My daughters first name?
Carden.
An outpatient clinic nurse assesses a blood glucose level of 75 mg/dL in a patient who has been on a low carbohydrate diet for the last 10 days. Is this blood glucose level WNL?
Yes, it is within normal limits. Document the finding.
REMEMBER: Normal blood sugar is between 70 and 120 mg/dL.
Anytime there are abnormalities noted (ie. drainage, crusting, or redness of the eye).
A patient who is terminally ill is described during shift report as having Cheyne-Stokes breathing. On assessment, the nurse anticipates finding:
a breathing pattern of dyspnea followed by a short period of apnea.
The nurse inserting an NG tube through the nostril into the back of the throat of a patient would instruct the patient to do what next:
drop head forward and begin to swallow.
The patient should be instructed to tip the head forward and begin to swallow to help advance the tube through the esophagus.
Orthostatic hypotension
a decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within three minutes of standing when compared with blood pressure from the sitting or supine position.
When assisting a patient with a severe visual impairment who wishes to feed himself, the nurse could best facilitate the patient’s eating by:
orienting the patient to the position of foods on the plate using a clock face description.
It is best to orient a visually impaired patient to the position of the foods on the plate by describing the plate as if it is a clock face (3 o’clock, 6 o’clock, and so on).