A client has not voided for 6 hours and has a distended bladder and the nurse inserted an indwelling Foley catheter. After the tubing is secured and the collection bag is hung on the bed frame, the nurse notices that 800 ml of urine has drained into the collection bag. What would be the appropriate nursing action for the safety of the client?
a. clamp the tubing for 30minutes and then release
b. raise the collection bag high enough to slow the rate of drainage
c. provide suprapubic pressure to maintain a steady flow of urine
d. check the specific gravity of the urine
RATIONALE: Rapid emptying of a large volume of urine may cause engorgement of pelvic blood vessels and hypovolemic shock. Clamping the tubing for 30minutes allows for equilibration to prevent complication.
A nurse is caring for a client with a chest tube attached to a Pleurevac drainage system. Which of the following actions would the nurse must avoid preventing a tension pneumothorax?
a. clamping the chest tube
b. taping the connection between the chest tube and the drainage system
c. adding water to the suction chamber as it evaporates
d. maintaining the collection chamber below the client’s waist
RATIONALE: To prevent a tension pneumothorax, the nurse avoids clamping the chest tube, unless specifically ordered. Clamping the chest tube is contraindicated by agency policy.
A client with a chest tube attached to a Pleurevac drainage system wants to get out of bed. While the nurse is assisting the client, the chest tubing accidentally gets caught in the bed rail and disconnects and the Pleur-Evac drainage system falls over and cracks. The nurse takes which immediate action?
a. clamps the chest tube
b. applies a petroleum gauze over the end of the chest tube
c. immerses the chest tube in a bottle of sterile normal saline
d. calls the physician
RATIONALE: If a chest tube accidentally disconnects from the tubing of the drainage apparatus, the nurse should first reestablish an underwater seal to prevent tension pneumothorax and mediastinal shift. This can be accomplished by reconnecting the chest tube, or in this case, immersing the end of the chest tube in a bottle of sterile normal saline or water. The physician should be notified after taking the corrective action.
A nurse is making a plan of care for a female client receiving enteral feedings. The nurse emphasizes which nursing diagnosis as the highest priority for this client?
a. Risk for Aspiration
b. Risk for Deficient Fluid Volume
c. Imbalanced Nutrition, Less than Body Requirements
RATIONALE: Any condition in which gastrointestinal motility is slowed or esophageal reflux is possible places a client at risk for aspiration.
A client is scheduled for indirect visualization of the larynx to assess the function of the vocal cords. As the physician is performing the procedure, the nurse instructed the client to do which of the following?
a. roll the tongue to the back of the mouth
b. Hold the breath
c. Breathe normally
d. Try to swallow
RATIONALE: Indirect laryngoscopy is done to assess the function of the vocal cords or to obtain tissue for biopsy. Observations are made during rest and phonation by using a laryngeal mirror. The client is placed in an upright position to facilitate passage of the laryngeal mirror into the mouth and is instructed to breathe normally. The tongue cannot be moved back because it would occlude the airway. Swallowing can not be done with the mirror in place. The procedure takes longer that the time the client would be able to hold the breath, and this action is ineffective.
A registered nurse instructed a nursing student to check the breath sound of the client. As she is observing the nursing student in auscultation, the nurse intervene when the student perform which of the inappropriate action?
a. places the stethoscope directly to the client’s skin
b. uses the bell of the stethoscope
c. asks the client breathe slowly
d. asks the client to sit up straight
RATIONALE: The bell of the stethoscope is not use to auscultate the breath sounds. The client ideally should sit up and breathe slowly and deeply through the mouth. The diaphragm of the stethoscope which is warmed before use, is placed directly on the client’s skin, not over a gown or clothing.
A physician tells a nurse to instill otic solution to a adult client left ear. While performing the procedure, the nurse avoids doing which of the following?
a. placing the tip of the dropper on the edge of the ear canal
b. warming the solution to room temperature
c. placing the client on the side-lying position with the ear facing up
d. pulling the auricle backward and upward
RATIONALE: The dropper is not allowed to touch any object or any part of the client’s skin. The solution is warmed before use. The client is placed on the side with the affected ear upward. The nurse pulls the auricle backward and upward to adult client and instills the medication by holding the dropper about 1cm above the ear canal.
A female client has undergone left pneumonectomy. A nurse is formulating a plan of care to this client. The nurse plans to do which of the following immediate action after the clients was transferred from the post anesthesia care unit?
a. position the client supine
b. assist the client to sit in the bedside chair
c. place the client’s intravenous fluid
d. position the client on the left side
RATIONALE: Following pneumonectomy, the fluid status of the client is monitored closely to prevent fluid overload, because the size of the pulmonary vascular bed has been reduced as a result of pneumothorax. Complete lateral turning and positioning is avoided. The client should remain on bed rest and the head of the bed should be elevated to promote lung expansion.
A client becomes disoriented during the night and at risk for falls. The physician ordered for vest restraint from 10:00 PM to 7:00 AM. At 11:00 AM the charge nurse makes rounds on all of the clients with the vest restraints. Which observation by the charge nurse would indicate that the nurse who cared for this client performed an unsafe action of the use of the restraint.
a. the restraint was applied tightly
b. a hitch knot was used to secure the restraint
c. the client’s record indicates that the restraint must be released every two hour
d. The call light was placed within reach of the client
RATIONALE: Restraint should be applied securely not tightly because it could impair circulation.
A physician scheduled the client for pulmonary angiography. The client is fearful about the procedure and asks the nurse if it is painful and if there is radiation exposure. The nurse provides reassurance to the client based on the understanding that:
a. There is absolutely no pain, although a moderate amount of radiation must be used to get accurate result.
b. There is very mild pain throughout the procedure and the exposure to radiation is negligible
c. The procedure is somewhat painful, but there is minimal exposure to radiation
d. Discomfort my occur with needle insertion and there is minimal exposure to radiation
RATIONALE: Pulmonary angiography involves minimal exposure to radiation. The procedure is painless although the client may feel discomfort with insertion of the needle for the catheter that is used for dye injection.