RN Learning System Fundamentals Practice Quiz 2 (Questions and Answers With Rationale) | Verified

RN Learning System Fundamentals Practice Quiz 2 (Questions and Answers With Rationale) | Verified A nurse is changing the dressings for a client who has two Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation? Abdominal binder Montgomery straps Hypoallergenic tape Plastic tape {{Correct Ans- Montgomery straps Penrose drains consist of a flexible rubber or silicone tube which is left inside the site of the surgery to promote drainage of blood, lymph and other fluids by ... The nurse should apply the least restrictive priority-setting framework. This framework assigns priority to nursing interventions that are least restrictive to the client, as long as those interventions do not jeopardize client safety. Least restrictive interventions promote client safety without using restraints. The nurse should only use physical or chemical restraints when the safety of the client, staff, or others is at risk. The nurse should plan to use Montgomery straps to minimize irritation to the skin near the incisional area. Montgomery straps are adhesive strips applied to the skin on either side of the surgical wound. The adhesive strips have holes for using gauze to tie the dressing securely. When the dressing is changed, the ties are released, the dressing replaced, and the ties secured again without removing the adhesive strips. An abdominal binder can hold the dressings in place and decrease skin irritation while the client rests in bed, however, when the client ambulates, the dressings tend to slide out. Securing the dressings first is the preferred method when applying a binder. Therefore, the nurse should use a less restrictive intervention first.Hypoallergenic tape is used when a client is sensitive to adhesive material; however, hypoallergenic tape can cause skin sensitivity when frequently removed and reapplied. The nurse should use a less restrictive intervention first. Plastic tape adheres well to skin and can cause skin sensitivity when frequently removed and reapplied. However, the nurse should use a less restrictive intervention first. A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following locations should the nurse secure the urinary catheter tubing? Lateral thigh Lower abdomen Mid-abdominal region Medial thigh {{Correct Ans- Lower abdomen After inserting an indwelling urinary catheter, the nurse should secure the catheter tubing to the client's upper thigh or lower abdomen, by using adhesive tape or catheter securement device. This location will decrease tension and trauma to the urethra. A nurse is assessing a client who has an onset of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client? "Does the medication you're taking relieve the pain?" "Can you point to where the pain is the worst?" "What do you think caused the onset of your pain?" "Changing positions makes your pain worse, right?" {{Correct Ans- "What do you think caused the onset of your pain?" The nurse is using an open-ended question that allows the client to respond with a wide range of information by using more than one or two words. A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take? Maintain suction while removing the NG tube. Instill 100 mL of air into the NG tube before removal. Pinch the NG tube while removing the tube. Instruct the client to breathe in and out during the removal of the NG tube. {{Correct Ans- Pinch the NG tube while removing the tube. The nurse should pinch the NG tube while removing the tube to decrease the risk of aspiration of any gastric contents. The nurse should instill 50 mL of air into the tube to clear the contents of gastric drainage and decrease the risk of aspiration on removal of the tube. The nurse should instruct the client to take a deep breath and to hold it during the removal of the NG tube to close off the glottis and decrease the risk of aspiration of any gastric contents.