Nokea
A 49-year-old male with a tracheostomy tube confides to the nurse during a clinic visit that he is beginning to avoid sexual activity because of the increased tracheostomy secretions. Which of the following statements by the nurse will be most helpful to the client?
- A. I have a special medication to decrease secretions.
- B. Avoid fluid intake 2 hours before sexual activity.
- C. Place a thin piece of gauze over the tracheostomy.
- D. Wash the tracheostomy area with deodorizing antibacterial soap before sexual activity.
Correct Answer: C
Rationale: Placing a thin gauze over the tracheostomy can absorb secretions, reducing embarrassment and enabling the client to engage in sexual activity comfortably.
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The nurse supervises a nursing student administering a purified protein derivative (PPD) skin test. Which action by the student requires follow-up by the nurse?
- A. Inserts the needle, bevel up at a 15-degree angle
- B. Instructs the client that the test will be read in 48-72 hours
- C. Selects a site 3 to 4 finger widths below the antecubital space
- D. Administers the test using a 20-gauge needle, 2 inches long
Correct Answer: D
Rationale: A PPD test requires a 26- or 27-gauge needle, 1/2 inch long, for intradermal administration.
A client with rheumatoid arthritis is experiencing fatigue. Which nursing intervention is most appropriate?
- A. Encourage high-intensity exercise.
- B. Plan rest periods throughout the day.
- C. Increase carbohydrate intake.
- D. Limit fluid intake to reduce swelling.
Correct Answer: B
Rationale: Planning rest periods conserves energy and reduces fatigue in rheumatoid arthritis.
The client with Addison's disease is taking glucocorticoids. Which of the following statements indicates that the client understands how to take the medication?
- A. Various circumstances increase the need for glucocorticoids, so I will need to adjust the dosage.'
- B. My need for glucocorticoids will stabilize and I will be able to take a predetermined dose once a day.'
- C. Glucocorticoids are cumulative, so I will take a dose every third day.'
- D. I must take a dose every 6 hours to ensure consistent blood levels of glucocorticoids.'
Correct Answer: A
Rationale: Glucocorticoid needs vary with stress, requiring dose adjustments in Addison's disease to prevent adrenal crisis.
A nurse is teaching a client about cystoscopy preparation. What instruction should be included?
- A. Fast for 8 hours before the procedure.
- B. Drink plenty of water before the test.
- C. Expect to stay overnight in the hospital.
- D. Empty the bladder before the procedure.
Correct Answer: D
Rationale: Emptying the bladder ensures a clear view during cystoscopy and reduces discomfort.
A client has the following arterial blood gas values: pH, 7.52; PaO2, 50 mm Hg; PaCO2, 28 mm Hg; HCO3ˆ’, 24 mEq/L. Based upon the client's PaO2, which of the following conclusions would be accurate?
- A. The client is severely hypoxic.
- B. The client is low but poses no risk for the client.
- C. The client's PaO2 level is within normal range.
- D. The client requires oxygen therapy with very low oxygen concentrations.
Correct Answer: A
Rationale: A PaO2 of 50 mm Hg indicates severe hypoxia (normal is 75–100 mm Hg), requiring urgent oxygen therapy. It poses significant risk and is not normal or manageable with low concentrations.