Exam (elaborations)
Nursing Week 2: Technical Skills
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Nursing Week 2: Technical Skills Nursing Week 2: Technical Skills Nursing Week 2: Technical Skills
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Week 2: Technical SkillsA client requires long-term ventilator therapy. The client has a tracheostomy in place and requires
frequent suctioning. Which technique should the nurse use? - verified answer intermittent suction
while withdrawing the catheter
To prevent hypoxia, the nurse should use intermittent (not continuous) suction while withdrawing
the catheter. Suctioning shouldn't last more than 10 seconds at a time. Neither intermittent nor
continuous suctioning should be applied while the catheter is being advanced.
When cleaning the skin around an incision and drain site, what should the nurse do? - verified
answer Clean the incision and drain site separately.
When cleaning the skin around an incision and drain, the nurse should clean the incision and drain
separately to avoid contaminating either wound. This is applying the principle of working from the
least contaminated area to the most contaminated area. In this case, both areas are fresh wounds
and should be kept separate.
A client is returned to his room after a subtotal thyroidectomy. Which piece of equipment is most
important for the nurse to keep at the client's bedside? - verified answer Tracheostomy set
After a subtotal thyroidectomy, swelling of the surgical site (the tracheal area) may obstruct the
airway. Therefore, the nurse should keep a tracheostomy set at the client's bedside in case of a
respiratory emergency. Although an indwelling urinary catheter and a cardiac monitor may be used
for a client after a thyroidectomy, the tracheostomy set is more important. A humidifier isn't
indicated for this client.
The nurse is observing a client with cerebral edema for evidence of increasing intracranial pressure
and monitors the blood pressure for signs of widening pulse pressure. The client's current blood
pressure is 170/80 mm Hg. What is the client's pulse pressure? Record your answer using a whole
number. - verified answer 90
Pulse pressure is the difference between the systolic blood pressure and the diastolic blood
pressure. For this client, pulse pressure is 170 - 80 = 90.
In which parts of the body should the nurse administer an intramuscular injection to a 6-month-old
infant? - verified answer the lateral middle third of the thigh between the greater trochanter and the
knee
,The appropriate site to give an injection to an infant is the vastus lateralis. The dorsogluteal,
ventrogluteal, and deltoid muscles are areas for older children and adults.
The correct landmark for obtaining an apical pulse is the - verified answer left fifth intercostal space,
midclavicular line.
The correct landmark for obtaining an apical pulse is the left fifth intercostal space in the
midclavicular line. This area is the point of maximum impulse and the location of the left ventricular
apex. The left second intercostal space in the midclavicular line is where the nurse auscultates
pulmonic sounds. The apical pulse isn't obtained at the midaxillary line or the seventh intercostal
space in the midclavicular line.
The nurse collects a urine specimen from a client for a culture and sensitivity analysis. What should
the nurse do to preserve the specimen? - verified answer Send it to the laboratory immediately.
A specimen for culture and sensitivity should be sent to the laboratory promptly so that a smear can
be taken before organisms start to grow in the specimen.
A multigravid client visits the clinic because she suspects that she is pregnant but is unable to tell the
nurse when her last menstrual period began. The client has a history of preterm birth. The nurse
instructs the client that the gestational age of the fetus can be estimated by which procedure? -
verified answer ultrasonography
An ultrasound can provide a fairly accurate estimate of the fetal gestational age through various
measurements of fetal landmarks.Amniocentesis is appropriate for determining genetic deviations
and fetal lung maturity (lecithin-to-sphingomyelin ratio).Percutaneous umbilical blood sampling is
used to detect genetically transmitted (inherited) blood disorders, acidosis, or infection.Alpha-
fetoprotein levels are performed between the 15th and 20th weeks of gestation to determine if
neural tube defects are present.
A nurse is assessing a 4-year-old child's peripheral IV line, observing that it is not infusing. What is
the first action the nurse should take to correct this situation? - verified answer Reposition the
child's extremity.
The most likely reason for difficulty running an IV in this age group is a positional issue of the child or
extremity because of the child's activity level.
, When administering a tube feeding to a client through a percutaneous feeding tube, how should the
nurse position the client? - verified answer Head of bed elevated 30 to 45 degrees
The client should be positioned with the head of the bed raised 30 to 45 degrees to help prevent
aspiration and promote gastric emptying. Having the head of the bed raised to 90 degrees would
also help prevent aspiration, but is uncomfortable and not feasible for many clients being tube fed,
particularly those that are critically ill or who receive continuous feedings. Lying a client supine while
tube feeding should be avoided, because it increases the risk for aspiration and can lead to many
negative outcomes. Side lying on the left side with the top leg bent at the knee would be the proper
positioning for an enema or rectal examination, not a tube feeding, because it would also increase
the risk of aspiration and should be avoided.
A 27-year-old primigravid client with insulin-dependent diabetes at 34 weeks' gestation undergoes a
nonstress test, the results of which are documented as reactive. What should the nurse tell the
client that the test results indicate? - verified answer There is evidence of fetal well-being.
The nonstress test is considered reactive when two or more fetal heart rate accelerations of at least
15 bpm occur (from a baseline fetal heart rate of 120 to 160 bpm), along with fetal movement,
during a 10- to 20-minute period. A reactive nonstress test indicates fetal heart rate accelerations
and well-being. There is no indication for further evaluation (such as a contraction stress test).
However, contraction stress tests are commonly scheduled for pregnant clients with insulin-
dependent diabetes in the latter part of pregnancy and are repeated periodically until birth.
Chorionic villus sampling is usually performed early in the pregnancy to detect fetal abnormalities.
The nurse observes a constant gentle bubbling in the water seal column of a water seal chest
drainage system. What should the nurse do next? - verified answer Check the connectors between
the chest and drainage tubes and where the drainage tube enters chest drainage system.
There should never be constant bubbling in the water-seal system; normally, the bubbling is
intermittent. Constant bubbling in the water-seal bottle indicates an air leak, which means that less
negative pressure is being exerted on the pleural space. Decreasing the suction will not reduce the
leak. It is not necessary to notify the HCP until the system has been checked and the problem
identified.
While making rounds, the nurse finds a client with chronic obstructive pulmonary disease sitting in a
wheelchair, slumped over a lunch tray. After determining the client is unresponsive and calling for
help, what should the nurse do next? - verified answer Open the client's airway.
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