Chapters 57, 55, 58
NCLEX REVIEW QUESTIONS
- The nurse explains to the client that the most important reason for inserting an indwelling catheter is to: remove urine continuously from the bladder
- While performing a sterile procedure, part of the sterile field becomes wet. Which action should the nurse take? Set up a new sterile field.
- Prior to inserting a urinary catheter into the male client who is uncircumcised, which action should the nurse take? : retract the foreskin
- After teaching a client how to change a dressing, it is most important for the nurse to document which information? Client’s ability to perform sterile technique
- When cauterizing a male client, the nurse knows that the catheter is inserted into the bladder when: urine flows into the tubing
- A client has a painful pressure ulcer that looks like a 1-cm* 2-cm blister. The nurse should document this pressure ulcer and the physician would probably diagnose it as stage : 2
- A client with darkly pigmented skin has an area that appears persistently purple and feels warm and boggy. The physician would most likely diagnose this as a : stage 1 pressure ulcer
- Most surgical wounds heal by : primary intention
- The nurse recognizes that which factor in a client history is most significantly related to his or her formation of pressure ulcer? : restricted to bed
- Which of the following foods would the nurse recommend to promote wound healing? : meals and citrus fruits
- What is the most important goal of care of a client who is receiving sterile wound irrigation?: cleanse the wound
- A nurse is preparing to inject insulin into a diabetic patient. Which of the following teachings is appropriate for the process? : surgical asepsis
- A nurse is required to care for a newborn. Which of the following should be used to disinfect the nurses hands before she handles the baby? : Hexachlorophene
- A 35 year old female client is cauterized after a hysterectomy , and the urine flow seems undiminished after withdrawal of a normal quantity of urine. What immediate action the nurse take? : remove the catheter and inform the physician
- The inanimate objects in the blood collection room need to be cleaned. Which of the following should be used for the mechanical cleansing of inanimate objects? : antiseptic cleanser
- A nurse is preparing to assist the ehalthcare provider in performing a lumbar puncture, which is sterile procedure. The nurse has put on sterile gloves and sterile gown. Where on the surgical gown can the nurse safely place his gloves hands while waiting for the healthcare provider to be ready? : between the nipples and the waist
- In the operating room, the nurse touches the strings of the surgical gown worn by another nurse with the sterile gloves hand. What is the next step to be taken by the nurse? Discard the gloves and use a fresh pair
- A 30 year old male client is cauterized after major abdominal surgery. For which of the folowing reasons is th drainage bag placed in a position lower than that of the clients’s urinary bladder after catherization? : for proper drainage of urine
- A nurse is preparing to assist the surgeon in major operation. What are the guidelines taken into consideration to maintain sterility? : reaching over a sterile field should be avoided, unless sterile clothing is worn, the mask must be changes for a new sterile mask if it becomes wet, when the nurse is pouring a sterile solution, the inside of the bottle should not be touched.
- Given below are the fewer steps for removal of a retention catheter. Arrange the steps in the correct order. : adjust bed to the comfortable height, deflate the ballon by completely aspirating all the fluid, ask the client to inhale and exhale slowly and deply, gently and slowly pull the catheter out.
- A 30 year old client has received mutiple wounds on her arm and face in motor vehicle accident. The nurse uses betadine to clean the wounds. What term best describes this process? : disinfection
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