Nokea
The nurse is reviewing discharge teaching with the parent of a pediatric client who has a new tracheostomy. Which of the following statements by the parent would indicate a correct understanding of the teaching?
- A. I will immediately change the tracheostomy tube if my child has difficulty breathing
- B. I will provide deep suctioning frequently to prevent any airway obstruction.
- C. I will remove the humidifier if my child develops more secretions.
- D. I will travel with two tracheostomy tubes, one of the same size and one a size smaller.
Correct Answer: D
Rationale: Carrying two tracheostomy tubes (same and smaller size) is correct for emergency preparedness. Immediate tube changes, frequent deep suctioning, or removing humidifiers can worsen the situation or are unsafe.
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The nurse is caring for clients who are having the following procedures. Which client should be asked about allergies to shellfish?
- A. The client who is having an arthroscopy
- B. The client who is having an arthrocentesis
- C. The client who is having a myelogram
- D. The client who is having an electromyogram (EMG)
Correct Answer: C
Rationale: Myelograms often use iodine-based contrast; shellfish allergies may indicate iodine sensitivity, requiring verification. Arthroscopy, arthrocentesis, and EMG do not typically involve contrast.
A client with a diagnosis of acoustic neuroma asks the nurse to explain what is wrong with his hearing. The nurse's response is based on the knowledge that an acoustic neuroma is:
- A. A malignant tumor of the inner ear with rapid metastasis
- B. A malignant tumor of the fifth cranial nerve that affects hearing and chewing
- C. A benign tumor of the auditory nerve that may cause destruction to the cerebellum
- D. A highly vascular benign lesion of the middle ear that arises from the jugular vein
Correct Answer: C
Rationale: An acoustic neuroma is a benign tumor of the eighth cranial (auditory) nerve that can affect hearing and balance and may cause compression of nearby structures, such as the cerebellum. Answer A is incorrect because acoustic neuromas are benign, not malignant. Answer B is incorrect because it involves the fifth cranial nerve, which is unrelated. Answer D refers to a glomus tumor, not an acoustic neuroma.
The nurse is caring for a 6-month-old client who has a new tracheostomy. Which of the following findings would indicate that the client's airway requires suctioning? Select all that apply.
- A. Audible gurgling
- B. Heart rate of 110/min
- C. Increased irritability
- D. Oxygen saturation of 88%
- E. Respiratory rate of 30/min
Correct Answer: A,C,D
Rationale: Audible gurgling, irritability, and low oxygen saturation (88%) indicate airway obstruction or secretions requiring suctioning. Normal heart rate (110/min) and respiratory rate (30/min) for a 6-month-old do not necessitate suctioning.
The nurse knows that a client with right-sided hemiplegia understands teaching regarding ambulation with a cane if she states:
- A. I will hold the cane in my right hand.
- B. I will advance the cane and the right leg together.
- C. I will be able to walk only by using a walker.
- D. I will hold the cane in my left hand.
Correct Answer: D
Rationale: For right-sided hemiplegia, the cane is held in the left hand to support the weaker right side. Holding it in the right hand or advancing it with the right leg is incorrect. A walker is not always necessary.
Which of the following laboratory values requires immediate follow-up?
- A. phenytoin level of 8 mcg/mL (32 mcmol/L) for a client who is receiving enteral feedings
- B. digoxin level of 1.3 ng/mL (1.7 nmol/L) for a client who has a heart rate of 62/min
- C. lithium level of 0.8 mEq/L (0.8 mmol/L) for a client who is reporting a decreased appetite
- D. International normalized ratio (INR) of 3 for a client who has a prosthetic aortic valve
Correct Answer: A
Rationale: Phenytoin levels of 8 mcg/mL are subtherapeutic (therapeutic range: 10-20 mcg/mL), especially with enteral feedings that reduce absorption, requiring immediate adjustment.