Community Health Nursing Quiz 3

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 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 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 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 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 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 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 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 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 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: