Clinical Practice Question questions and
answers
A client who has had an indwelling catheter removed is expected to: Select all
that apply. - ANSWER>>Discomfort, Have the ability to identify signs and
symptoms of urinary tract infection
. Which of the following statements shows the best understanding of the
information
required for safe removal of an indwelling catheter, thus minimizing the client's
risk of injury? - ANSWER>>"I'll need a 10 mL syringe to deflate the balloon"
Which of the following nursing actions is most appropriate when the male client
who is having an indwelling urinary catheter inserted complains of pain as the
balloon is being inflated? - ANSWER>>Withdraw the fluid from the catheters
balloon
To minimize the client's risk for infection, the nurse asks the unlicensed and
ancillary staff to empty the urinary drainage bag how often? - ANSWER>>When
the bag is between 1/2 and 2/3 full
The nurse has inspected the client's perineum in preparation for the insertion of
an indwelling urinary catheter. Which of the following actions should the nurse
complete next? - ANSWER>>Remove soiled gloves and perform hand hygiene.
Which of the following actions will best minimize the client's risk for injury during
the insertion of an indwelling urinary catheter? - ANSWER>>Assessing the client
for allergies related to latex, antiseptic, tape, and/or an iodine-based substance
Which of the following characteristics is most likely that of a stage 2 pressure
ulcer? - ANSWER>>Blister
,Which of the following assessment observations would be most indicative of
healthy wound healing? - ANSWER>>Presence of granulation
Which of the following actions will minimize the risk of cross-contamination
during the cleansing process of an infected abdominal surgical wound? -
ANSWER>>Using a new gauze pad for each cleansing stroke
During a surgical dressing change, which is the appropriate time for the nurse to
don sterile gloves? - ANSWER>>After removing the original dressing materials
Which of the following actions is most likely to protect the staff during dressing
change of an infected abdominal wound? - ANSWER>>Using appropriate personal
protective equipment
Which of these interventions is most likely to minimize pain caused by a dressing
change? - ANSWER>>Pre-medicating the patient with an analgesic 30-45 minutes
before the intervention
. Which of the following observations noted of a surgical suture line during the
initial dressing change is the best indicator of a complication that should be
reported to the physician immediately? - ANSWER>>Frank bleeding from the
wound
Which is the best nursing action when there is no urine flow after an indwelling
urinary catheter is inserted into a female client? - ANSWER>>Remove the
catheter and start all over with a new kit and catheter
When preparing an injection of mixed insulin that includes 12 units of NPH and 5
units
of regular insulin, the nurse initially confirms proper dosage when: - ANSWER>>5
units of clear insulin is visible in the syringe
, When preparing an injection that contains both short- and intermediate-acting
insulins, the nurse will most effectively ensure the effectiveness of this insulin
injection by initially: - ANSWER>>Inserting air into the cloudy (intermediate-
acting) insulin
When preparing to administer an injection of insulin, the nurse recognizes that
which of the following areas is not an appropriate injection site? - ANSWER>>Area
within 2 inches of the umbilicus
The nurse is preparing to administer insulin to a client. Which of the following
actions will best ensure the client's safety? - ANSWER>>. Determining the
patient's current blood glucose level
The nurse is preparing a rectal suppository for insertion into an elderly client. To
best facilitate insertion, the nurse should initially: - ANSWER>>Place the client in a
left side-lying position with the top leg flexed up
The client who has a history of nighttime confusion is to receive several oral
medications at bedtime. To best ensure that the client has swallowed the
medication, the nurse should: - ANSWER>>Ask the patient to open his mouth
after swallowing the tablets
The client refuses the scheduled dose of an antibiotic claiming that the
medication causes him to be nauseous. To best minimize the client's risk of injury,
the nurse should: - ANSWER>>Notify the prescriber of the client's reason for
refusing the medication
While reviewing a newly written medication order, the nurse notes that the route
of administration has been omitted from the prescription. The nurse best
addresses this situation by: - ANSWER>>Immediately calling the prescriber to
complete the medication prescription
answers
A client who has had an indwelling catheter removed is expected to: Select all
that apply. - ANSWER>>Discomfort, Have the ability to identify signs and
symptoms of urinary tract infection
. Which of the following statements shows the best understanding of the
information
required for safe removal of an indwelling catheter, thus minimizing the client's
risk of injury? - ANSWER>>"I'll need a 10 mL syringe to deflate the balloon"
Which of the following nursing actions is most appropriate when the male client
who is having an indwelling urinary catheter inserted complains of pain as the
balloon is being inflated? - ANSWER>>Withdraw the fluid from the catheters
balloon
To minimize the client's risk for infection, the nurse asks the unlicensed and
ancillary staff to empty the urinary drainage bag how often? - ANSWER>>When
the bag is between 1/2 and 2/3 full
The nurse has inspected the client's perineum in preparation for the insertion of
an indwelling urinary catheter. Which of the following actions should the nurse
complete next? - ANSWER>>Remove soiled gloves and perform hand hygiene.
Which of the following actions will best minimize the client's risk for injury during
the insertion of an indwelling urinary catheter? - ANSWER>>Assessing the client
for allergies related to latex, antiseptic, tape, and/or an iodine-based substance
Which of the following characteristics is most likely that of a stage 2 pressure
ulcer? - ANSWER>>Blister
,Which of the following assessment observations would be most indicative of
healthy wound healing? - ANSWER>>Presence of granulation
Which of the following actions will minimize the risk of cross-contamination
during the cleansing process of an infected abdominal surgical wound? -
ANSWER>>Using a new gauze pad for each cleansing stroke
During a surgical dressing change, which is the appropriate time for the nurse to
don sterile gloves? - ANSWER>>After removing the original dressing materials
Which of the following actions is most likely to protect the staff during dressing
change of an infected abdominal wound? - ANSWER>>Using appropriate personal
protective equipment
Which of these interventions is most likely to minimize pain caused by a dressing
change? - ANSWER>>Pre-medicating the patient with an analgesic 30-45 minutes
before the intervention
. Which of the following observations noted of a surgical suture line during the
initial dressing change is the best indicator of a complication that should be
reported to the physician immediately? - ANSWER>>Frank bleeding from the
wound
Which is the best nursing action when there is no urine flow after an indwelling
urinary catheter is inserted into a female client? - ANSWER>>Remove the
catheter and start all over with a new kit and catheter
When preparing an injection of mixed insulin that includes 12 units of NPH and 5
units
of regular insulin, the nurse initially confirms proper dosage when: - ANSWER>>5
units of clear insulin is visible in the syringe
, When preparing an injection that contains both short- and intermediate-acting
insulins, the nurse will most effectively ensure the effectiveness of this insulin
injection by initially: - ANSWER>>Inserting air into the cloudy (intermediate-
acting) insulin
When preparing to administer an injection of insulin, the nurse recognizes that
which of the following areas is not an appropriate injection site? - ANSWER>>Area
within 2 inches of the umbilicus
The nurse is preparing to administer insulin to a client. Which of the following
actions will best ensure the client's safety? - ANSWER>>. Determining the
patient's current blood glucose level
The nurse is preparing a rectal suppository for insertion into an elderly client. To
best facilitate insertion, the nurse should initially: - ANSWER>>Place the client in a
left side-lying position with the top leg flexed up
The client who has a history of nighttime confusion is to receive several oral
medications at bedtime. To best ensure that the client has swallowed the
medication, the nurse should: - ANSWER>>Ask the patient to open his mouth
after swallowing the tablets
The client refuses the scheduled dose of an antibiotic claiming that the
medication causes him to be nauseous. To best minimize the client's risk of injury,
the nurse should: - ANSWER>>Notify the prescriber of the client's reason for
refusing the medication
While reviewing a newly written medication order, the nurse notes that the route
of administration has been omitted from the prescription. The nurse best
addresses this situation by: - ANSWER>>Immediately calling the prescriber to
complete the medication prescription
