A client is receiving continuous tube feeding. How often would
the nurse plan to check residual? Correct Answers every 4
hours
A nurse collecting a nasopharyngeal swab on a patient explains
to the patient that this test is most often used to screen for which
of the following? Correct Answers viral infections
A nurse is assessing a client with a nasogastric tube. The nurse
would expect the normal color and consistency of gastric fluid to
be which of the following? Correct Answers green colored fluid
with particles
A nurse is assessing a client with continuous bladder irrigation
(CBI) and notes that the volume of irrigant instilled into the
client's bladder is more than the volume of drainage in the
collection bag. Which of the following steps would the nurse
take? Select all that apply. Correct Answers check tubing for
kinks
palpate client bladder for distention
A nurse is changing a client's ostomy device and notes the
presence of peristomal excoriated skin. What would be the
nurse's best action to take? Correct Answers Make sure the
appliance hole is not cut too large, exposing more than 1/8th
inch of skin.
A nurse is changing a client's peripheral venous access dressing.
Which nursing action is correct? Correct Answers Press the
, chlorahexidine applicator against the skin using a back-and-forth
motion
A nurse is delivering oxygen to a patient via an oxygen mask.
Which of the following is a recommended guideline for this
procedure to decrease the risk for impaired skin integrity?
Correct Answers Remove the mask and dry the skin every 2 to
3 hours if the oxygen is running continuously.
A nurse is preparing to administer an inhaled medication to a
client. The client states, "I have taken this inhaler for years."
What is the best action the nurse would take next? Correct
Answers Ask the client to teach-back the steps to take when
self-administering this medication
A nurse is preparing to administer oxygen to a client with
pneumonia via a mask with a reservoir. What step would the
nurse take prior to placing the mask on the client's face? Correct
Answers Allow the reservoir bag to fully inflate with oxygen
A nurse is preparing to drain the bladder of a client by inserting
a catheter for 5 minutes and then removing the catheter. What
type of catheter would the nurse plan to use for this procedure?
Correct Answers Intermittent urethral catheter (Straight
catheter)
A nurse is preparing to remove a client's surgical incision
sutures. The best method to use for suture removal is which of
the following? Correct Answers With non-sterile gloved hands,
remove every other suture to assure incision integrity