Procedures I
A physician orders “enemas until clear” for a constipated patient. After three enemas, the patient is still not clear of fecal matter. How should the nurse continue?
Notify the physician that three enemas have been provided and fecal matter is still present
If a spinal injury is suspected, before the rescuer starts CPR, the trachea should be opened with a _______ maneuver.
Jaw-thrust
A patient tearfully declares the use of relaxation techniques does not work for her. What is the best action for the nurse to implement?
Encourage the patient to try again
A patient has pain in the left arm secondary to coronary insufficiency. This is an example of what type of pain?
Referred pain
When preparing a patient for sleep, dimming the lights and decreasing the noise levels are examples of nursing interventions. What are these interventions designed to do?
Decrease environmental stimuli
During insertion of a Foley catheter, the patient grimaces as the balloon is inflated. What is the immediate reaction of the nurse?
Deflate the balloon and advance the catheter into the bladder
Musculoskeletal injuries such as sprains and strains typically are treated initially according the the RICE mnemonic. The acronym stands for __, __, __, __, and __.
Rest, ice, compression and elevation
The nurse is attempting to control bleeding in a patient with a profusely bleeding scalp wound. What is the most effective initial treatment of this bleeding?
Apply direct pressure
A patient is receiving an opioid narcotic. What common side effect should the nurse be aware of when assessing this patient?
Constipation
The nurse is caring for a patient using patient-controlled analgesia (PCA). What is a major advantage to this method?
Quicker
A nurse is preparing to insert a nasogastric tube. The nurse should place the patient in which position?
High Fowler position
The patient is to be catheterized for residual urine. The nurse must perform this catheterization within how many minutes following voiding?
10 minutes
The nurse is teaching a patient with epistaxis about the best way to control bleeding. What information will the nurse relay to this patient?
Place ice on the nose and pinch the nostrils
A young athlete asks the nurse why he felt little pain when he broke his leg during a game. What does the nurse describe as having an effect on this patient’s perception of pain?
Endorphins
The nurse is using a pain scale of 0 to 10 to assess pain in a postoperative patient. What is considered the maximum pain level at which a patient can usually function effectively?
5
Before inserting a nasogastric tube, what measurement should the nurse take?
Tip of the nose to the earlobe to the xiphoid process
The process for collecting a blood specimen for measuring blood glucose levels begins by asking the patient to hold the selected arm at his or her side for 30 seconds. From what anatomic location is the specimen obtained?
Side of the finger
While on break in the hospital cafeteria a nurse witnesses her pregnant coworker start to choke. The coworker is conscious, but unable to breathe. Where should the nurse administer thrusts?
The chest
The nurse explains that transcutaneous electric nerve stimulation (TENS) provides a continuous mild electric current to the skin. How does the TENS unit act to reduce pain?
Blocks pain impulses
What is the term for the cleanest part of a voided urine specimen that is collected after voiding is initiated and before it is finished?
Midstream specimen
When treating an infant choking on a foreign body, the nurse should use a combination of _________ and ________ to successfully dislodge the object.
Back blows, chest thrusts
What should the nurse instruct the patient to do, regarding oral intake, when preparing the patient for a bone scan?
Encourage water intake
The patient’s lower chest has been punctured with a knife that is still in place. What should the nurse’s first action be?
Immobilize the knife with dressings and tape
The nurse teaches noninvasive pain relief techniques, such as guided imagery, biofeedback, and relaxation. What is the primary advantage of these techniques?
Gives the patient some control
A patient tells the nurse he is reluctant to report his pain because he does not want to be a bother. What problems is the nurse aware that unrelieved pain can cause?
Depression
Respiratory dysfunction
Decreased GI motility
Irritability