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Name: ____________________________________________ Score: ______________________ 1. The nurse asks each client preoperatively for the name and dose of all prescription and overthe –counter medications taken before surgery because they: a. May cause allergies to develop b. Are automatically ordered postoperatively c. Should always be taken the morning of surgery with sips of water d. May create a greater risks for anesthetic and surgical complications 1. Family members should be included when the nurse teaches the client preoperative exercise so they can: a. Coach the client postoperatively b. Demonstrate to the client at home c. Relieve the nurse by getting the client to do exercise every 2 hours d. Practice with the client while waiting to be taken to the operating room 1. Because an older adult is at increased risk for respiratory complications after surgery, the nurse should: a. Withhold the pain medications and ambulate the client every 2 hours b. Monitor fluid and electrolyte status every shift and vital signs with temperature every 4 hours c. Orient the client to the surrounding environment frequently and ambulate the client every 2 hours d. Encourage the client to turn, deep breathe and cough frequently, and ensure adequate pain control 1. A client with a prothrombin time (PT) or an activated partial thromboplastin time (APTT) greater than normal is at risk postoperatively for: a. Infection b. Bleeding c. Low urine output d. Cardiac dysrhythmias 1. When the client is deep breathing and coughing, it is important to have the client sit because this position: a. Is more comfortable b. Facilitates expansion of the thorax c. Helps the client to splint with a pillow d. Increases the client’s view of the room and is more relaxing
compared with an adjacent or opposite area on the body. Postoperatively the client with a closed abdominal wound reports a sudden “pop” after coughing. place tight binder over the areas. Fresh bleeding . notify surgeon. notify surgeon. Infection – notify surgeon and anticipate administration of antibiotic b. Stage I c. Pneumonia – listen to breath sounds.1. In the postoperative period you note that the client has a heart rate of 130 beats per minute and a respiratory rate of 32 breaths per minute. indicating: a. What do you suspect. the sutures are open and pieces of small bowel are noted at the bottom of the now opened wound. The correct intervention would be to: a. When repositioning an immobile client. prepare to administer dantrolene sodium. tissue consistency (firm or beefy feel). This client has sensitive skin and requires special bed linens c. may include changes in one or more of the following: skin temperature (warmth or coolness). and what intervention is indicated? a. and monitor vital signs frequently 1. Place several cold packs over the areas. and anticipate order for chest radiography c. the red spot blanches with fingertip touch. itching). Stage III b. Cover the area with sterile gauze. this is likely to indicate a wound evisceration d. Stage II d. a reaction that causes the blood vessels to dilate in the injured area 1. protecting the skin around the wound c. When the nurse examines the surgical wound site. A stage III pressure ulcer needing the appropriate dressing d. and ask the client to remain in bed for 30 minutes because this is a minor opening in the surgical wound and should reseal quickly 1. the nurse notices redness over the bony prominence. A local skin infection requiring antibiotics b. Allow the area to be exposed to air until all drainage has stopped b. When the area is assessed. a. and/or sensation (pain. This type of pressure ulcer has an observable pressure related alteration of the intact skin whose indicators. you also assess jaw muscle rigidity and rigidity of limbs. Cove the areas with sterile saline-soaked towels and immediately notify the surgical team. Reactive hyperemia. Hypertension – check blood pressure. Stage IV 1. and anticipate administration of antihypertensive d. Serous drainage from a wound is defined as: a. abdomen and chest. Malignant hyperthermia – notify surgeon/anesthesia provider immediately.
Denial . Increased rate and depth of respiration 1. Clear.b. To improve blood flow to an injured part d. Algor mortis d. Cold the formula before administering it 2. Kussmaul’s breathing is. Encourage her to accept or to replace the lost person d. Place the client on the left side of the bed b. To relieve edema b. Provide opportunity to the client to tell their story c. When providing a continuous enteral feeding. It is the gradual decrease of the body’s temperature after death. Beige to brown and foul smelling 1. Bargaining c. Rigor mortis c. d. Depression b. a. a. None of the above 1. A complication of warm compress is indicated: a. Tell her not to cry and it will be better b. Thick and yellow c. watery plasma d. Livor mortis b. For a client who is shivering c. Attach the feeding bag to the current tubing c. To protect bony prominences from pressure ulcer 1. Prolonged gasping inspiration followed by a very short. Presty has terminal cancer and she refuses to believe that loss is happening ans she assumes artificial cheerfulness. Discourage the client in expressing her emotions 933 1. Shallow breaths interrupted by apnea b. Elevate the head of the bed d. usually inefficient expiration c. Marked rhythmic waxing and waning of respirations from very deep to very shallow breathing and temporary apnea. What stage of grieving is she in? a. which of the following action is essential for the nurse to do? a. Which of the following is appropriate nursing intervention for a client who is grieving over the death of her child? a.
Stoicism d. Frequent bowel sounds 1. Introduce the feeding slowly c. The nurse listens to Mrs. Pulse rate greater than 100 beats per minute b. Numbness c. The symptomatic quadrant last d. Open the drainage bag and pour out the urine c. Which of the following is inappropriate nursing action when administering NGT feeding? a. Sullen’s lungs and notes a hissing sound or musical sound. A female patient with a terminal illness is in denial. Wheezes b. Jake is complaining of shortness of breath. Preparatory grief 1.d. A scrub nurse in the operating room has which responsibility? a. The symptomatic quadrant first c. The nurse understands that tachypnea means: a. Indicators of denial include: a. Vesicular 2. Any quadrant b. Disconnect the catheter from the tubing and get urine d. Use sterile gloves when obtaining urine b. The Nurse documents this as: a. Shock dismay b. Assist the patient in fowler’s position 4. The nurse assesses his respiratory rate to be 30 breaths per minute and documents that Jake is tachypneic. Instill 60ml of water into the NGT after feeding d. Rhonchi c. Blood pressure of 140/90 c. Respiratory rate greater than 20 breaths per minute d. Gurgles d. Assisting with gowning and gloving . When examining a patient with abdominal pain the nurse in charge should assess: a. Aspirate urine from the tubing port using a sterile syringe 3. Positioning the patient b. Place the feeding 20 inches above the pint of insertion of NGT b. What nursing action is appropriate when obtaining a sterile urine specimen from an indwelling catheter to prevent infection? a. Acceptance 2. The symptomatic quadrant either second or third 5.
Ginger ale . B and C 1. And then leave it at the bedside c. inspection. a. Sputum culture c. To evaluate a patient for hypoxia. Orange juice b. and then leave the medication at the bedside 1. percussion c. Internal Respiration d. which is least likely implemented? The client should void before the procedure The client should be placed on a lithotomy position Warm hands should be used in palpation Warm stethoscope should be used in auscultation 1. What is the correct sequence in conducting an abdominal examination? a. Before an abdominal assessment. the physician is most likely to order which laboratory test? a.c. c. percussion b. Perfusion c. Applying surgical drapes 1. Arterial blood gas (ABG) analysis 1. d. Handling surgical instruments to the surgeon d. percussion. The process of exchanging gases between the cells and the blood is known as: 1403 a. palpation. palpation. Auscultation. Palpation. What should the nurse in charge do? a. auscultation. Red blood cell count b. Inspection. Whole milk c. percussion. Which of the following food will the nurse avoid to give to the client? a. A patient is in the bathroom when the nurse enters to give a prescribed medication. Ventilation b. Total hemoglobin d. percussion. palpation d. The physician ordered a low-sodium diet to the client. Return shortly to the patient’s room and remain there until the patient takes the medication d. Inspection. inspection 1415 1. Tell the patient to be sure to take the medication. b. auscultation. Wait for the patient to return to bed. Leave the medication at the patient’s bedside b.
encouraging the patient to deep breathe and cough to facilitate removal of upper-airway secretions d. Which of the following instructions would the nurse include? a. Which of the following is not considered a water soluble vitamin? a. limit suction pressure to 150-180 mmHg b. remove the inner cannula 1. Vitamin K d. Vitamin B1 c. 1.d. The nurse encourages the client to wear compression stockings. Compression stockings promote venous return b. Compression stockings divert blood to major vessels c. aucultating the lungs to determine the baseline data to assess the effectiveness of suctioning b. Which of the following is not considered a fat soluble vitamin? a. administering 100% oxygen to reduce the effects of airway obstruction during suctioning. Compression stockings decreases workload on the heart d. Vitamin B3 b. Vitamin C . What is the rationale behind in using compression stockings? a. The nurse is to perform tracheal suctioning. Vitamin A b. Compression stockings improve arterial circulation 1. Replace the catheter with a new one every 24 hour 696 1. Perform the Valsalva maneuver to promote insertion d. suction for 15-20 seconds c. the nurse should implement safety measures. A nurse is providing a discharge instruction to the client about the self-catheterization at home. Black coffee 1. During tracheal suctioning. wear eye goggles d. During tracheal suctioning. Vitamin E 2. Lubricate the catheter with Vaseline c. which nursing action is essential to prevent hypoxemia? a. Wash the catheter with soap and water after each use b. removing oral and nasal secretions c. Which of the following should the nurse implements? a.
A client is scheduled for NGT Feeding. Oliguria b. You reinstill the 40 cc of residual volume and added the 250 cc of feeding ordered by the doctor. Niacin d. Another name for Vitamin B1 is ____ . Enuresis d. Vitamin K 6. 250 cc b.c. Which of the following foods is not high in potassium? a. a. How much will you put in the client’s chart as input? a. a. Pantothenic Acid b. For clearance mechanism such as coughing b. Cyanocobalamin c. Bananas c. 290 cc c. Tomatoes d. Which of the following match with the definition: a poor output of urine? a. Pyuria c. Riboflavin 7. Transport gases to the lower airways . Vitamin E d. Thiamine b. egg yolk and soy oil? a. Vitamin A b. Vitamin D d. Oranges b. you determined that he has 40 cc residual from the last feeding. Diuresis 1. Vitamin D c. Riboflavin c. Turnips 5. 350 cc d. Checking the residual volume. Vitamin B12 3. Another name for Vitamin B12 is ____ . You then instill 60 cc of water to clear the lumen and the tube. 310 cc 1. Pyridoxine d. Which of the following vitamins will be the most common in: leafy green vegetables. Cobalamin 4. Which one of the following is NOT a function of the Upper airway? a.
Requires energy to be carried out . Fr. 5 1. 10-15 mmHg d. You are using a Wall unit suction machine. which one of these should you use for Mr. The wall unit is not functioning. How much pressure should you set the valve before suctioning Mr. Protect the lower airway from foreign matter 1. Among the following foods. Fr. Raisin d. 15-25 mmHg 1. Warming. 10 d. You are about to set the suction pressure to be used to Mr. 100-120 mmHg d. How much pressure of suction equipment is needed to prevent trauma to mucus membrane and air ways in case of portable suction units? a. Fr. Stridor is commonly heard during expiration d. 12 c. 200-350 mmHg c. Filtration and Humidification of inspired air d. Banana 1. A passive process b. 50-95 mmHg b. The length of which is half of the length of Inspiration c. Which of the following if done by a nurse indicates deviation from the standards of NGT feeding? a. Height of the feeding should be 12 inches about the tube point of insertion to allow slow introduction of feeding c. Avocado c. Which of the following is TRUE about Expiration? a. There are four catheter sizes available for use. which has the highest amount of potassium per area of their meat? a. Hamilton. you then try to use the portable suction equipment available. 5-10 mmHg c. Ask the client to position in supine position immediately after feeding to prevent dumping syndrome d. Hamilton? a.c. Hamilton? a. Do not give the feeding and notify the doctor of residual of the last feeding is greater than or equal to 50 ml b. Clamp the NGT before all of the water is instilled to prevent air entry in the stomach 1. 18 b. Cantaloupe b. 10-15 mmHg 1. Fr. 2-5 mmHg b.
Residual volume 1. growth and tissue repair d. Expiratory reserve volume c. Expiratory reserve volume c. for the body to use in growth and development b. It is a process in which digested proteins. An independent nursing action 1. Instilling air in the NGT and listening for a gurgling sound at the epigastric area 1. This is the amount of air remained in the lungs after a forceful expiration a. energy use. Inspiratory reserve volume b. Inspiratory reserve volume b. Which of the following is not true about the Large Intestine? a. Functional residual capacity d. vitamins and carbohydrates are transported into the circulation c. Should last only for 60 minutes c. fats.1. Administer medications d. Residual volume 1. All but one of the following is a purpose of steam inhalation a. Refers to the extra air that can be inhaled beyond the normal tidal volume a. minerals. Warm and humidify air c. Patient assumes position for 10 to 15 minutes b. Which of the following is the BEST method in assessing for the correct placement of the NGT? a. Done best P. It is called large intestine because it is longer than the small intestine 1.C d. When should a nurse suction a client? . It absorbs around 1 L of water making the feces around 75% water and 25% solid b. It is the process in which food are broken down. It is a sterile body cavity d. Aspirating gastric content to check if the content is acidic d. Functional residual capacity d. It is a chemical process that occurs in the cell that allows for energy production. X-Ray b. Promote bronchoconstriction 1. Immerse tip of the tube in water to check for bubbles produced c. Which of the following is true about nutrition? a. The stool formed in the transverse colon is not yet well formed c. It is the study of nutrients and the process in which they are use by the body 1. Mucolytic b. Which of the following is TRUE in postural drainage? a.
Gelatin c. Which of the following is included in a full liquid diet? a. Central venous access devices are beneficial in pediatric therapy because: a. They are difficult to see. Irritability 6. They cannot be dislodged.6 3. He mentions that. Hard candy b. Pallor 5. will he?” How will the nurse answer the patient? a.2 2. Which is not a clear liquid diet? a. Flaring of Nares a. Tachycardia 3. d. Partial Rebreather mask 1. Tachypnea 2. Cyanosis 4.a. Nasal Cannula b. As desired As needed Every 1 hour Every 4 hours 1. d. 2. Coffee with Coffee mate d. It is a minor procedure performed on the unit and does not necessitate .4 1. b. Bouillon 1. b. Non Rebreather mask d. c. Simple Face mask c. b. A male patient needs a percutaneously inserted central catheter (PICC) for prolonged IV therapy. They don’t frighten children. Pineapple juice with pulps d.5 2. “at least the doctor won’t be wearing surgical garb. c. Which of the following is the initial sign of hypoxemia in an adult client? 1. 1. Use of the arms is not restricted. Pureed vegetable meat c. “You are correct. Mashed potato 1. d. Popsicles b. He knows it can be inserted without going to the operating room. Which of the following oxygen delivery method can deliver 100% Oxygen at 15 LPM? a. c.
Pain and discomfort. 5.surgical attire. How will the nurse reply? a. the doctor inserting the PICC will wear a cap.” b. and sterile gown and gloves.” d. Check results of liver function tests 7. Makes the catheter less visible to other people. Blood glucose of 350 mg/dl 8. Infection. mask. Record the number of stools per day .” b. The primary complication of a central venous access device (CVAD) is: 6. “To decrease the risk of infection. Although all of the following nursing actions must be included in the plan of care of this child. mask. Occlusion of the catheter as the result of an intra-lumen clot. Decreases the risk of infection. “It depends on the doctor’s preference. Use aseptic technique during dressing changes b. Monitor serum glucose levels d. Thrombus formation in the vein. He asks the nurse whether the insertion will hurt. Nurse Jamie is administering the initial total parenteral nutrition solution to a client.” d. “You will have general anesthesia so you won’t feel anything. what is the most important action on the part of the nurse? a. Prevents the patient’s clothes from having contact with the catheter d. “The insertion site will be anesthetized. “It will be inserted rapidly. not a cap. This is the first day of TPN therapy.” 4. a.” 3. Increases the patient’s comfort level. Urine output of 300 cc in 4 hours c. which one would be a priority at this time? a. or sterile gown. What is the purpose of “tunneling” (inserting the catheter 2-4 inches under the skin) when the surgeon inserts a Hickman central catheter device? Tunneling: a. and any discomfort is fleeting. “You will receive sedation prior to the procedure.” c. d. “Most doctors only wear sterile gloves. Temperature of 37. When caring for a client with total parenteral nutrition (TPN).5 degrees Celsius b. b. Maintain central line catheter integrity c. A male patient is to receive a percutaneously inserted central catheter (PICC). Poor skin turgor d. c. c.” c. A 2 year-old child is receiving temporary total parental nutrition (TPN) through a central venous line. b. Which of the following assessments requires the nurse’s immediate attention? a. Threading the catheter through the vein is not painful.
Which of the following would best help him during his depression? a. You should prepare for which of the following FIRST? a.Insisting that Ruby should talk with you because it is not good to keep everything inside c. You now feel that Irma’s family could be helpful if they knew what Irma has told to you.Leaving her alone because she is uncooperative and unpleasant to be with d. she speaks to you in confidence. 9. It is important for us nurses to be aware of how we view suffering. 1.Arrange for visitors who might cheer him b. Placement of a second IV line .“I’m giving up” 1. socially.” c.Coming back periodically and indicating your availability if she would like you to sit with her b. who is terminally ill and recognizes that he is in the process of losing everything and everybody he loves. Marla. who is dying.” b. Ruby who has been told she has terminal cancer. She was brought to the ER by a police woman. pain. and even our death as well as its meaning.“What’s the use?” d. Andrea loses consciousness. Placement of nasogastric tube b.Sit down and talk with him for a while c. has accepted his impending death? a.Sit silently with him 1. financially and emotionally. turns away and refuses to respond to you. Leo. is depressed. Maintain strict intake and output records c.“I’m ready to go. 90 years old has planned ahead for her death-philosophically. You can best help her by: a. What should you do first? a) Tell the physician who in turn could tell the family b) Obtain Irma’s permission to share the information in the family c) Tell Irma that she has to tell her family what she told you d) Make an appointment to discuss the situation with the family 1. illness. That way we can help our patients cope with death and dying. Irma is terminally ill. Monitor for cardiac arrhythmias Situation – One of the realities that we are confronted with is our mortality.Encourage him to look at the brighter side of things d.Encouraging her to be physically active as possible 1. This is recognized as: a) Acceptance that death is inevitable b) Avoidance of the true situation c) Denial with planning for continued life d) Awareness that death will soon occur Situation – Andrea is admitted to the ER following an assault where she was hit on the face and head. Emergency measures were stated.b. Sterile technique for dressing change at IV site d.“I have resigned myself to dying. Which of the following statements would best indicate that Ruffy.
The patient is dead. the nurse keeps which of the following in mind? a. When formulating the plan of care. You know the apnea is seen in client’s with cheyne stoke respiration. weighing the client daily b. b. Monitoring the serum blood urea nitrogen (BUN) 2. The nurse prepares to deliver the lunch tray to the client and checks the food tray to be sure that which of the following is true? a. Sodiums foods are restricted b. Low-residue diet d. Which of the following is the most appropriate diet for this client at this time? a. Low-sodium diet 3. You know that this rhythm of respiration is defined as: a. All food item are lukewarm in temperature c. Eupnea 3. A period of hypercapnea and hypoxia due to cessation of respiratory effort inspite of normal respiratory functioning 1. the breathing stops c. Inability to breath in a supine position so the patient sits up in bed to breathe. 4. Full-liquid diet c. APNEA is defined as: a. There is an absence of breathing for a period of time usually 15 seconds or more d.c. Aspiration is a concern with a nasogastric tube feeding. A nurse is developing a plan of care for a client with a nasogastric (NG) tube feeding in place. Monitoring the temperature d. Which nursing intervention would specifically provide assessment data related to the most common complication related to TPN? a. Biot’s b. At least one serving of low-fat milk is served. A female client tells the home health nurse that she has not had a stool since coming home from the hospital after surgery 4 days ago. Endotracheal intubation or surgical airway placement d. Kussmaul’s c. Monitoring I&O c. Cheyne Stokes d. All food items are liquid at body temperature d. A physician has ordered a clear liquid diet for a postoperative client. Andrea’s respiration is described as waxing and waning. . High-fiber diet b. A nurse is caring for a client who is receiving total parenteral nutrition (TPN) via a central line. CT scan of head 2.
A blood pressure of 120/80 mmHg d. Preparing an air lock when drawing up the medication c. A urine output that is pale yellow in color. which of the following assessment data would indicate to the nurse that the dehydration is not resolved? a. Administer a Fleet enema c. Which of the following is not considered a right of medication? a. Wait 30 minutes abd then administer another enema b. To medicate with antidiarrheal medications everyday. Using a Z-tract method for injection. A registered nurse (RN) has instructed a nursing assistant (NA) to administer soap solution enemas until clear to a client scheduled for a colonoscopy. d. The nurse plans to include which of the following interventions in the plan of care? a. d. A nurse is preparing a plan of care for a client receiving enteral feedings via a gastrotomy tube (G-tube). d. The rate of the feeding needs to be increased if the infusion rate falls behind schedule. The client needs to be maintained in supine position. 8. To provide oral fluids three times per day b. An oral temperature of 98. The client is receiving intravenous fluids. To use sterile technique when administering the tube feedings. 9. The NG tube needs to be changed with every other feeding. Limit . Changing the needle after drawing up the dose and before injection. c. b.8 F 7. To check around the stoma site for skin irritation. A registered nurse (RN) is supervising a licensed practical nurse (LPN) administer an intramuscular (IM) injection of iron to an assigned client. The RN would intervene if the nurse observed the LPN perform which of the following? a. Stop administering the enemas until the physician is notified. Which of the following instructions would the RN give to the NA? a. Administer an oil-retention enema d. 5. A nurse is caring for a client with a diagnosis of dehydration. Route d. Dose b. 6. c.b. Time c. The NA tells the nurse that three enemas have been administered and that the client is still passing brown liquid stool. c.033 b. A urine specific gravity of 1. Massaging the injection site well after injection.
and showing signs of acute respiratory distress. Respiratory rate b. Call respiratory therapy for a prescribed ABG (arterial -blood gas) analysis 14. complaints of discomfort in the bladder and urethra the nurse should first: a.10. The nurse finds him extremely restless. Color of mucus membranes c. An order is written for oxygen by nasal cannula at 2 liters per minute. Pineda. if an allergic reaction to the blood occurs. Which assessment is most useful in assessing the adequacy of the oxygen therapy? a. who has urinary retention catheter in place. Take no special action b. Shake the vial of blood before transporting it to the lab d. Mr. A child is to receive a blood transfusion. the nurse's first intervention should be: a. Pineda. Keep the client on bed rest for 2 hours 16. the nurse should: a. He is using accessory muscles for breathing and is diaphoretic and cyanotic 13. Administered medication which has been ordered for pain d. nurse Rose teaches how to do this without compromising the catheter. Refrigerate the specimen c. When Mr. Slow the flow rate c. Irrigate the catheter with prescribed solutions 12. Notify the physician b. Mr. Store on dry side of utility room d. When a female client with an indwelling urinary (Foley) catheter insists on walking to the hospital lobby to visit with family members. Villa needs frequent monitoring of arterial blood gases. Pulmonary function tests d. Relieved the symptoms with an ordered antihistamines Situation: (Questions 90 – 92). Apply pressure to the puncture site for 5 minutes c. Which client action indicates an accurate understanding of this information? . Milk the tubing gently c. Discard and collect a new specimen later 11. Call the physician b. Villa was admitted to the respiratory floor with COPD. If the specimen cannot be sent immediately to the laboratory. incoherent. Stop the blood immediately d. A routine urinalysis is ordered for Mr. Assess vital signs and neural vital signs c. Following the drawing of arterial blood gasses it is essential for the nurse to do which of the following? a. Administered oxygen as ordered b. Arterial blood gases 15. Encourage the client to cough an deep breath b. The best initial action by the nurse is to: a. Check the patency of the catheter d.
b. c. Specific gravity of 1. Elevate the client’s head at least 45 degrees and administer the feeding d. Intermittent flow of irrigation solution and prevention of hemorrhage. Inhale and exhale quickly c. Fluid intake should be approximately equal to the urine output. Hold the feeding b. What is appropriate action for the nurse to take? a. Remove the tube and reinsert when the respiratory distress subsides d. Fluid intake should be double the urine output. Quickly insert the tube b. Continuous inflow and intermittent outflow of irrigation solution. d. The client loops the drainage tubing below its point of entry into the drainage bag 17. 20.a. In addition to balloon inflation. b. A nurse is inserting a nasogastric tube in an adult male client. Fluid intake should be half the urine output. Nurse Agnes is reviewing the report of a client’s routine urinalysis. Take and hold a deep breath d. During the procedure. the client begins to cough and has difficulty breathing. d. The client keeps the drainage bag below the bladder at all times. b. Nurse Oliver checks for residual before administering a bolus tube feeding to a client with a nasogastric tube and obtains a residual amount of 150 mL. c. the nurse is aware that the functions of the three lumens include: a. The client clamps the catheter drainage tubing while visiting with the family. Notify the physician immediately c. Urine pH of 3. The nurse should instruct the client to do which of the following just before the nurse removes the tube? a. Which of the following is the appropriate nursing action? a.0 c. Nurse Claudine is reviewing a client’s fluid intake and output record. Fluid intake and urine output should relate in which way? a. A triple-lumen indwelling urinary catheter is inserted for continuous bladder irrigation following a transurethral resection of the prostate. Pull back on the tube and wait until the respiratory distress subsides 22. Perform a Valsalva maneuver . 19.03 b. Discard the residual amount and proceed with administering the feeding 21. Fluid intake should be inversely proportional to the urine output. Absence of glucose 18. d. Absence of protein d. Intermittent inflow and continuous outflow of irrigation solution. The client sets the drainage bag on the floor while sitting down. A nurse is preparing to remove a nasogartric tube from a female client. Continuous inflow and outflow of irrigation solution. Exhale b. c. Which value should the nurse consider abnormal? a. Reinstill the amount and continue with administering the feeding c.
To administer the medication. The nurse writes down which instruction for the client to follow before the test? a. Eat a regular supper and breakfast c.23. Aspirate the nasogastric tube after medication administration to maintain patency c. Palpates the liver at the right rib margin c. Clamp the nasogastric tube for 30 minutes following administration of the medication d. A female client being seen in a physician’s office has just been scheduled for a barium swallow the next day. Change the suction setting to low intermittent suction for 30 minutes after medication administration 24. Continue to take all oral medications as scheduled d. Monitor own bowel movement pattern for constipation 25. The nurse is performing an abdominal assessment and inspects the skin of the abdomen. Nurse Joy is preparing to administer medication through a nasogastric tube that is connected to suction. Fast for 8 hours before the test b. the nurse would: a. Palpates the abdomen for size b. Percusses the right lower abdominal quadrant . Listens to bowel sounds in all for quadrants d. Position the client supine to assist in medication absorption b. The nurse performs which assessment technique next? a.
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