Nurs 221 Test 1 Study Questions, Exams of Nursing

Download Nurs 221 Test 1 Study Questions and more Exams Nursing in PDF only on Docsity! Nurs 221 Test 1: Study Questions A patient complains of pain during a dressing change. What would be the most effective intervention the nurse could initiate at the next dressing change in order to reduce the patient's pain? - correct answer ✔Premedicate the patient with a prescribed analgesic 30 minutes before the intervention. Which action reduces the nurse's risk for infection when changing the dressing of an infected abdominal wound? - correct answer ✔Use appropriate personal protective equipment (PPE). What is the nurse's best response when additional bloody drainage appears on the initial abdominal dressing of a patient who had surgery 7 hours ago? - correct answer ✔Further assess the patient and the wound. When changing a patient's surgical dressing 24 hours postoperatively, when would the nurse apply sterile gloves? - correct answer ✔After removing the original dressing materials and performing hand hygiene a second time Which action would minimize the risk for cross-contamination while cleansing an infected abdominal surgical wound? - correct answer ✔Using a new gauze pad for each stroke while cleansing the wound Which personal protective equipment (PPE) will the nurse wear if there is a risk of a blood splash when caring for a patient? - correct answer ✔Gown, gloves, mask, and eye protection What will the nurse do first when preparing to apply personal protective equipment (PPE) before caring for a patient in isolation? - correct answer ✔Perform hand hygiene The nurse is discussing the guidelines for proper use of PPE by nursing assistive personnel (NAP). Which statement made by the NAP requires follow-up by the nurse? - correct answer ✔"I really dislike wearing a mask, so it's the first thing I take off." When removing a gown worn as personal protective equipment (PPE) while caring for a patient in isolation, why does the nurse avoid touching the outside of the gown? - correct answer ✔To prevent touching contaminated material with unprotected hands When delegating patient care that requires nursing assistive personnel (NAP) to use personal protective equipment (PPE), it is necessary for the nurse to do what first? - correct answer ✔Review the patient's need for a specific isolation precaution When irrigating a wound, how would the nurse know the right amount of pressure to apply? - correct answer ✔Follow the general rule of keeping the pressure between 4 and 15 psi. Which action should the nurse avoid before irrigating a patient's foot wound? - correct answer ✔Warm the irrigant to body temperature in the microwave. Which device is used for wound irrigation? - correct answer ✔19-gauge needle attached to a 35-mL syringe Which imaging study or diagnostic test would the nurse review to determine if the pressure ulcer on a patient's left heel is infected? - correct answer ✔Culture and sensitivity test Which action would the nurse take to reduce the risk of infection among patients and staff when administering an enema to an older adult patient with dementia? - correct answer ✔Perform hand hygiene before donning gloves. What is the best reason for the nurse to instruct a male patient to take slow, deep breaths during insertion of an indwelling urinary catheter? - correct answer ✔To promote relaxation When preparing to insert an indwelling urinary catheter in a male patient, it is important for the nurse to do what? - correct answer ✔Lubricate the first 5 to 7 inches of the catheter. Which observation indicates that instruction given to nursing assistive personnel (NAP) in caring for a patient with an indwelling urinary catheter has been effective? - correct answer ✔The excess catheter tubing has been coiled beside the patient's inner thigh. Which action will the nurse implement to reduce the risk of catheter- associated urinary tract infection (CAUTI) in a male patient with an indwelling urinary catheter? - correct answer ✔Clean the urinary meatus daily. While setting up the sterile field in preparation for inserting an indwelling urinary catheter, a male patient is incontinent of urine over most of the supplies. What action would the nurse take to reduce the patient's risk for infection? - correct answer ✔Replace all contaminated supplies, and begin the process again. During intermittent open bladder irrigation, a patient complains of pain. Which action would the nurse take first? - correct answer ✔Examine the drainage tubing for clots, sediment, and kinks. Which action would the nurse take to minimize a patient's risk for injury during urinary catheter irrigation? - correct answer ✔Use slow, even pressure when injecting the irrigating fluid. Which instruction might the nurse give to nursing assistive personnel (NAP) helping to care for a patient receiving bladder irrigation? - correct answer ✔"Measure and report the patient's temperature to me every 4 hours." Which action is most important in reducing the risk for infection in a patient receiving open intermittent irrigation of a urinary catheter? - correct answer ✔Cleaning the end of the drainage tubing with an antiseptic wipe before reconnecting it to the catheter Which action would the nurse take to manage continuous urinary catheter irrigation for a patient whose urine is bright red and contains clots? - correct answer ✔Increase the irrigation drip rate. When preparing to discharge a patient who had an indwelling urinary catheter removed 24 hours ago, the nurse would offer patient education regarding which common complication? - correct answer ✔Urinary tract infection (UTI) Which action would best minimize a patient's risk for infection during removal of an indwelling urinary catheter? - correct answer ✔The nurse or nursing assistive personnel (NAP) removing the catheter must employ clean technique. Which statement might the nurse make to nursing assistive personnel (NAP) caring for a patient who has just had an indwelling urinary catheter removed? - correct answer ✔"Tell me when and how much the patient first voids." Which nursing action minimizes a patient's risk for injury during removal of an indwelling urinary catheter? - correct answer ✔Checking the documentation for the volume of fluid used to inflate the balloon Which is not an expected outcome on a first voiding after catheter removal? - correct answer ✔Fever and back pain Which action would the nurse take to reduce the risk for a catheter-associated urinary tract infection (CAUTI) in a patient with an indwelling urinary catheter? - correct answer ✔Use the smallest-size catheter possible. Which action(s) would minimize the patient's risk for injury during insertion of an indwelling urinary catheter? - correct answer ✔Assessing the patient for allergies related to latex, antiseptic, tape, and/or iodine-based substances Which statement best illustrates the nurse's understanding of the role of nursing assistive personnel (NAP) when inserting an indwelling urinary catheter in a female patient? - correct answer ✔"Please direct the light to better illuminate the patient's perineal area." The nurse has completed the initial inspection of the patient's perineum and is preparing to insert an indwelling urinary catheter. Which action would the nurse complete next? - correct answer ✔Remove soiled gloves, and perform hand hygiene. A female patient placed in the dorsal recumbent position for the insertion of an indwelling urinary catheter tells the nurse that she "doesn't feel comfortable in this position" and that her "back really hurts." What is the nurse's best response? - correct answer ✔Reposition the patient in a side-lying position, with her upper leg flexed at the knee and hip. When preparing to move a patient in bed with the help of an assistant, which posture will both caregivers use to ensure their own safety? - correct answer ✔Flex the hips and knees. A patient who weighs 200 lbs. needs to be moved up in bed with the aid of a friction-reducing device. The nurse will prepare for this move by assembling how many caregivers? - correct answer ✔at least 3 In which position will the nurse place the patient to move him or her up in bed? - correct answer ✔Supine with the head of the bed flat A patient will be moved up in bed with the use of a friction-reducing device. How will the nurse place this device under the patient? - correct answer ✔Roll the patient from side to side, and place the device under the drawsheet. The nurse who is preparing to make an unoccupied bed should do what to ensure his or her personal safety? - correct answer ✔Place the bed at a comfortable working height. The nurse is preparing to change the soiled linen of a patient's unoccupied bed. Which precaution minimizes the risk of transmitting microorganisms? - correct answer ✔Perform hand hygiene and apply clean gloves. What would the nurse instruct the nursing assistive personnel (NAP) to do before making an unoccupied bed if the mattress is soiled? - correct answer ✔Wipe off moisture with antiseptic solution, and dry thoroughly. The nurse is reviewing placement of an unfitted bottom sheet with nursing assistive personnel (NAP) assigned to make an unoccupied bed. What should the nurse include in this teaching? - correct answer ✔The lower hem of the sheet should lie seam down and even with the bottom edge of the mattress. When making an unoccupied bed, where would the nurse place a waterproof pad? - correct answer ✔Over the bottom sheet. The nurse is preparing to make an occupied bed for a patient who is on aspiration precautions. What will the nurse do to ensure the safety of this patient during the bed change? - correct answer ✔Keep the head of the bed no lower than a 30-degree angle. The nurse is directing nursing assistive personnel (NAP) to make an occupied bed. What will the nurse say to minimize the risk of disease transmission to staff and patient during the bed change? - correct answer ✔"You'll need to apply Standard Precautions during this task." Which action ensures that a patient will not have unnecessary pain during a linen change? - correct answer ✔Administer a prescribed analgesic 30 to 60 minutes before the bed change if needed. The nurse is changing the bed linen of a patient on bed rest. When the nurse is ready to make the other side of the bed, what will the nurse do before having the patient turn onto the side that has already been made? - correct answer ✔Raise the side rails What will the nurse do right after placing a clean top sheet on the patient? - correct answer ✔Remove the bath blanket.