The nurse is caring for a client who is receiving bolus feedings through a nasogastric tube.  The nurse has aspirated the gastric contents and measured 175 ml of residual fluid.  The nurse should first: a. hold the feeding and report the findings to the team leaderb. inform the oncoming nurse during shift reportc. dispose of the gastric contents in the client’s commode and continue with administration of the tube feedingd. flush the tube with 120 ml of water

The nurse is assisting a patient to a sitting position when the patient suddenly complains of feeling that his surgical incision has separated. What does the nurse recognize that this indicates? a. Cellulitisb. Dehiscencec. Eviscerationd. Extravasation  

You are admitting a patient and are performing a skin assessment. Upon assessment, you find a stage III pressure ulcer on the patient’s ischial tuberosity. Identify all priority integumentary nursing assessments:  a. Pain assessmentb. Measurements, including depth, width, and heightc. Characteristics of exudate/ drainaged. Home nutrition regimene. Tissue quality in wound bed

The nurse assessing a patient’s wound notes thick, yellow drainage. How will the nurse most accurately document this finding? a. Serous drainageb. Purulent drainagec. Sanguineous drainaged. Serosanguineous drainage

The nurse assessing a patient’s wound notes pale red watery drainage. How will the nurse most accurately document this finding? a. Serous drainageb. Purulent drainagec. Sanguineous drainaged. Serosanguineous drainage  

The nurse is instructing a patient about the most important preventive technique for breaking the chain of infection. What technique is the patient learning about? a. Sterilizationb. Standard Precautionsc. Hand hygiened. Medical asepsis  

There is more than one way to check for nasogastric tube placement. One way is to test the PH of the gastric content. What would you expect the gastric content PH to be? a. Between 8-12b. Between 5-8c. Between 0.1-0.5d. Between 1-5  

The interval from the onset of nonspecific signs and symptoms to more specific symptoms is what stage of an infection? a. Convalescentb. Illnessc. Prodromald. Incubation

The nurse notes that the client’s surgical dressing is saturated and wet with sanguineous drainage one hour post-operatively. The nurse does which of the following? Select All That Apply. a. Notify the MD.b. Reinforce the dressing.c. Connect the drainage system to suction. d. Assess the client’s vital signs.e. Note the color and amount of drainage.

The nurse is concerned when a patient admitted with a diagnosis of pneumonia suddenly develops a urinary tract infection (UTI). What type of infection is this UTI considered? a. Viral infectionb. Bacterial infectionc. Health care–associated infectiond. Spore infection