PN3006 Quiz #2 - Questions And Correct Answers

PN3006 Quiz #2 - Questions And Correct Answers An obese patient is at risk for skin breakdown and subsequent pressure ulcers. Which strategies should the nurse who is caring for this patient include in his care? - ANSWER -Using a liftsheet and maintaining the head of the bed no higher than 30 degrees A patient has nonreactive hyperemia. What would be expected to be included in the patient's immediate care? - ANSWER -Use of the Braden Scale The nurse is checking for discoloration on a patient who has darkly pigmented skin. The nurse would be administering appropriate care if which technique was used? - ANSWER -The nurse uses a gloved hand to feel for warmth or change in tissue texture. An elderly patient who spends most of his waking hours in a chair is at risk for skin breakdown on his buttocks. What is the most appropriate action that the nurse should initiate with this patient? - ANSWER -Set a timer to ring at 15- to 20-minute intervals to remind the patient to change position. When accessing a CVAD catheter, what is the minimum amount of time the hub is scrub with an antiseptic swab? - ANSWER -15 seconds An implanted venous port is in use for intermittent IV therapy. Which measures should be considered when the medication is infused? - ANSWER -Use of a noncoring needle During the removal of a nontunneled CVAD, having the patient perform the Valsalva maneuver leads to: - ANSWER -prevention of air entry into the vein. Blood cultures are ordered for which type of patient? - ANSWER -One suspected of having CLABSI After blood specimens are obtained from a CVAD, the minimum volume of solution recommended for flushing is: - ANSWER -10mL What is the best nursing action when there is no urine flow after an indwelling urinary catheter is inserted into a female patient? - ANSWER -Determine whether the catheter is in the vagina, leave it there, and start over with a new catheter. Which intervention is appropriate when an indwelling urinary catheter is secured in a male patient? - ANSWER -Tape the catheter tubing to the lower abdomen, avoiding traction. When performing catheter care, what step helps prevent traction on the catheter and CAUTI? - ANSWER -Grasp the catheter with two fingers to stabilize the catheter. Which nursing intervention decreases the risk for catheter-associated urinary tract infection (CAUTI)? - ANSWER --Hanging the urinary drainage bag below the level of the bladder -Daily cleansing of the urinary meatus -Emptying the drainage bag using a separate receptacle for each patient An older diabetic patient with a lot of abdominal fat underwent abdominal surgery 4 days ago involving an 8-inch vertical incision. The nurse would be most concerned if which observation of the incision was made? - ANSWER -Serosanguineous drainage has increased since 2 days ago.