Nursing Skills
A nurse asks the unlicensed assistive personnel (UAP) to do each of the
following tasks after removal of the indwelling catheter. Which statements
illustrate appropriate delegation by the nurse? Select all that apply.
"Report to me the time and amount the client voids for the first time after
removal."
"If the client cannot void, reinsert the indwelling urinary catheter."
"Assess the client for bladder distension before the end of your shift."
"Explain to the client to let you know if the first time they void is uncomfortable."
"Educate the client on the signs of a urinary tract infection to watch for."- ANS -
-"Report to me the time and amount the client voids for the first time after
removal."
-"Explain to the client to let you know if the first time they void is uncomfortable."
\A nurse has just completed the insertion of a nasogastric (NG) tube. Click to
specify whether each potential nursing action is indicated or contraindicated.
Flush the NG with 60 mL of water
Obtain the ordered chest x-ray for placement verification
Aspirate a sample of gastrointestinal (GI) contents
Begin ordered feeding through the tube - ANS - Indicated:
-Obtain the ordered chest x-ray for placement verification
-Aspirate a sample of GI contents
Contraindicated:
-Flush the NG with 60 mL of water
-Begin ordered feeding through the tube
\A team of nurses on a surgical floor has noticed an increased development of
catheter-associated urinary tract infections (CAUTI) on the unit. They speak with
the infection control team at the hospital and decide to develop a "CAUTI Bundle"
to reduce the risk of these infections in their clients. What should the nurses
include in this bundle? Select all that apply.
Keep the catheter drainage bag at a level just above the client's bladder for
drainage
Ensure a urometer is a part of the drainage back prior to insertion
Use soap and water to clean the perineum on a regular basis
Document the reason for the catheter once every shift
Prior to any client transport, the urinary drainage bag should be emptied
Have two trained nurses involved in the catheter insertion procedure
, Use a sterile collection container when emptying the catheter drainage bag
Change out the catheter to a new one every 72 hours - ANS - -Ensure a urometer
is a part of the drainage back prior to insertion
-Use soap and water to clean the perineum on a regular basis
-Document the reason for the catheter once every shift
-Prior to any client transport, the urinary drainage bag should be emptied
-Have two trained nurses involved in the catheter insertion procedure
\After reviewing the electronic health record, answer the following question.
Which prescriptions need additional clarification or consultation with the
healthcare provider before performing? Select all that apply.
Medication order
Nasogastric tube insertion order
Diet order
Thromboembolic deterrent (TED) hose order
Admission orders - ANS - -Medication order
-Nasogastric tube insertion order
\The charge nurse reviews the census for the medical-surgical unit and
determines that sequential compression devices (SCDs) and antiembolic
stockings are needed for some of the clients. After reviewing the census,
highlight the clients who require SCDs or antiembolic stockings.- ANS - -BED 1
-BED 3
-BED 6
\The nurse cares for a client on continuous tube feeding through a nasogastric
tube. The nurse reviews the client's prescriptions. Click to specify whether the
listed medications aid in reducing the risk for aspiration, increase the client's risk
for aspiration, or does not affect the risk for aspiration while on continuous tube
feedings.
Metoclopramide
Alendronate
Omeprazole
Lisinopril
Sucralfate - ANS - Reduces Risks -->
-Metoclopramide
-Omeprazole
-Sucralfate
Increases risks -->
Alendronate
Does not affect risk -->
A nurse asks the unlicensed assistive personnel (UAP) to do each of the
following tasks after removal of the indwelling catheter. Which statements
illustrate appropriate delegation by the nurse? Select all that apply.
"Report to me the time and amount the client voids for the first time after
removal."
"If the client cannot void, reinsert the indwelling urinary catheter."
"Assess the client for bladder distension before the end of your shift."
"Explain to the client to let you know if the first time they void is uncomfortable."
"Educate the client on the signs of a urinary tract infection to watch for."- ANS -
-"Report to me the time and amount the client voids for the first time after
removal."
-"Explain to the client to let you know if the first time they void is uncomfortable."
\A nurse has just completed the insertion of a nasogastric (NG) tube. Click to
specify whether each potential nursing action is indicated or contraindicated.
Flush the NG with 60 mL of water
Obtain the ordered chest x-ray for placement verification
Aspirate a sample of gastrointestinal (GI) contents
Begin ordered feeding through the tube - ANS - Indicated:
-Obtain the ordered chest x-ray for placement verification
-Aspirate a sample of GI contents
Contraindicated:
-Flush the NG with 60 mL of water
-Begin ordered feeding through the tube
\A team of nurses on a surgical floor has noticed an increased development of
catheter-associated urinary tract infections (CAUTI) on the unit. They speak with
the infection control team at the hospital and decide to develop a "CAUTI Bundle"
to reduce the risk of these infections in their clients. What should the nurses
include in this bundle? Select all that apply.
Keep the catheter drainage bag at a level just above the client's bladder for
drainage
Ensure a urometer is a part of the drainage back prior to insertion
Use soap and water to clean the perineum on a regular basis
Document the reason for the catheter once every shift
Prior to any client transport, the urinary drainage bag should be emptied
Have two trained nurses involved in the catheter insertion procedure
, Use a sterile collection container when emptying the catheter drainage bag
Change out the catheter to a new one every 72 hours - ANS - -Ensure a urometer
is a part of the drainage back prior to insertion
-Use soap and water to clean the perineum on a regular basis
-Document the reason for the catheter once every shift
-Prior to any client transport, the urinary drainage bag should be emptied
-Have two trained nurses involved in the catheter insertion procedure
\After reviewing the electronic health record, answer the following question.
Which prescriptions need additional clarification or consultation with the
healthcare provider before performing? Select all that apply.
Medication order
Nasogastric tube insertion order
Diet order
Thromboembolic deterrent (TED) hose order
Admission orders - ANS - -Medication order
-Nasogastric tube insertion order
\The charge nurse reviews the census for the medical-surgical unit and
determines that sequential compression devices (SCDs) and antiembolic
stockings are needed for some of the clients. After reviewing the census,
highlight the clients who require SCDs or antiembolic stockings.- ANS - -BED 1
-BED 3
-BED 6
\The nurse cares for a client on continuous tube feeding through a nasogastric
tube. The nurse reviews the client's prescriptions. Click to specify whether the
listed medications aid in reducing the risk for aspiration, increase the client's risk
for aspiration, or does not affect the risk for aspiration while on continuous tube
feedings.
Metoclopramide
Alendronate
Omeprazole
Lisinopril
Sucralfate - ANS - Reduces Risks -->
-Metoclopramide
-Omeprazole
-Sucralfate
Increases risks -->
Alendronate
Does not affect risk -->
