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Exam 5 311 exam
Terms in this set (25)
The USASN needs to go back and read the Skills book if the student performs which action during the clinical day?
Hangs the catheter bag to the bedframe, making sure the tubing has dependent loops.
The USASN has been asked to collect a sterile urine specimen from an indwelling urinary catheter. The catheter has been in for 2 days. How should the student nurse proceed? (Select all that apply)
*The student explains to the client the urinary catheter will be clamped for 10-15 minutes in order for urine to accumulate.
*The student cleans the specimen collection port for 15 seconds with a disinfectant swab and allows it to dry.
*The student uses a needleless (Luer-Lok) system for specimen collection.
Dr. Swanzy is questioning the USASN regarding the condom catheter ordered for the client. Dr. Swanzy is concerned when the USASN states:
"After applying the condom, I will return in 2 hours to inspect the penis for swelling or discoloration."
The RN is preparing to insert an indwelling urinary catheter into an adult male. Which size catheter is most appropriate for the procedure?
The RN has an order to administer enteral feedings per a feeding tube (duo-tube) just inserted by the USASN and the clinical instructor. Prior to administering the initial feeding, the nurse confirms placement of the tube by:
X-ray film of chest/abdomen
The care provider has ordered placement of an NG tube for gastric decompression. Which action/s should the RN expect to perform as part of the procedure? (Select all that apply)
*Expect the care provider to order the NG to be connected to low intermittent suction.
*If using gastric pH paper, expect the pH to be less than 4.0 for gastric contents.
The RN is inserting an indwelling urinary catheter through the urethral opening of an adult female client and notices urine beginning to flow into the tubing. The next step in the procedure is:
Advance the catheter another 1-2 inches.
The RN assesses the new stoma to be dry and gray. Which action by the RN is most appropriate?
Document the appearance of the stoma and notify the health care provider.
The RN has an order to insert an NG tube. Which action/s should the nurse perform prior to insertion of the tube? (Select all that apply)
Verify the order and check 2 identifiers.
Assess the patency of each nostril.
The USASN is caring for a client reporting abdominal and rectal discomfort. The client has a history of constipation. The student suspects a fecal impaction. The USASN understands _________________about fecal impactions and fecal impaction removal: (Select all that apply)
Symptoms include anorexia, nausea, vomiting, abdominal pain, diarrhea, and urinary frequency.
Prevention is the key to managing fecal impaction.
When administering an enema to the adult client the USASN:
Inserts the tip of the tube 3 to 4 inches
The USASN is discussing intermittent or straight urinary catheterization with classmates.The student displays knowledge of the procedure by stating: (Select all that apply)
*Straight catheters are used to relieve bladder distention when a client is temporarily unable to void after surgery.
*Straight catheters are used to empty the bladder prior to surgery.
The USASN understands adequate oral intake is important to bladder health, especially when a client has an indwelling urinary catheter. Which assessment/s is/are valuable for determining patient fluid status? (Select all that apply)
Accurate intake and output measurements (I&O)
Three hours after an indwelling catheter is placed, the RN is making rounds and notes no urine in the catheter bag. The priority action is:
Inspect the system for kinks or leaks and palpate the bladder for distention.
The USASN is feeding the client when they suddenly choke on food. The priority action is:
Stop feeding immediately and suction the airway.
The USASN may serve which of the following if the client has a full liquid diet order: (Select all that apply)
chocolate milk shake
Following initial x-ray film verification of correct feeding tube placement the tube may be reliably monitored for proper placement by: (Select all that apply)
assessing the color of aspirate every 4-6 hours.
assessing the gastric pH every 4-6 hours.
Dr. Johnson is concerned when the clinical student states:
"Verification of feeding tube placement can be delegated to nursing assistive personnel (NAP) since the procedure is not sterile."
The USASN expects effluent from an ileostomy to be:
watery to thick liquid.
The client has an order for placement of an indwelling urinary catheter. Preparation for the procedure includes: (Select all that apply)
*assessment of allergies by checking the chart, armband, and asking the client about allergies.
*placing the female client in dorsal recumbent position.
*performing perineal care with soap and water.
Which statement/s regarding evidence based ostomy care is/are true. (Select all that apply)
*Some pouches have gas filters that allow flatus to escape.
*Patients undergoing ostomy surgery should have the stoma site marked before surgery.
*The stoma should be measured with each pouch change because the stoma will decrease in size 4-6 weeks following surgery.
The patient complains of abdominal cramping while receiving a soapsuds enema (SSE). The priority for the USASN is:
Lower the height of the enema bag.
What is the purpose of the initial stream of urine voided into the toilet during collection of a clean voided or midstream urine specimen?
The initial stream flushes out resident microorganisms and prevents transfer to the specimen.
The USASN inserts the urinary catheter into the vagina instead of the urinary meatus. The best action for the student is to:
leave the catheter in the vagina as a landmark and attempt to insert another sterile catheter.
The USASN is caring for a client receiving enteral nutrition. The USASN is safely administering the feedings when:
placing the client in high-Fowler's position.
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