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A 68-year-old client developed acute respiratory distress syndrome while hospitalized for pneumonia. After a respiratory arrest, an endotracheal tube was inserted. Several days later, numerous attempts to wean him from mechanical ventilation were ineffective, and a tracheostomy was created. For the first 24 hours following tracheostomy, it is important to minimize bleeding around the insertion site. The nurse can accomplish this by:
- A. Deflating the cuff for 10 minutes every other hour instead of 5 minutes every hour
- B. Avoiding manipulation of the tracheostomy including cuff deflation
- C. Reporting any signs of crepitus immediately to the physician
- D. Changing tracheostomy dressing only as necessary using one-half strength hydrogen peroxide to cleanse the site
Correct Answer: B
Rationale: The tracheal cuff should not be deflated within the first 24 hours following surgery. To minimize bleeding, any manipulation, including cuff deflation, should be avoided. Small amounts of crepitus are expected to occur; however, large amounts or expansion of the area of crepitus should be reported to the physician. The tracheostomy site may be changed as often as necessary, but site care should be done with normal saline.
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A healthcare worker is referred to the nursing office with a suspected latex allergy. The first symptom of latex allergy is usually:
- A. Oral itching after eating bananas
- B. Swelling of the eyes and mouth
- C. Difficulty in breathing
- D. Swelling and itching of the hands
Correct Answer: D
Rationale: Latex allergy often first presents as localized skin reactions, such as swelling and itching of the hands, due to direct contact with latex products.
The nurse is teaching a client with a history of type 2 diabetes about foot care. The nurse should tell the client to:
- A. Inspect feet daily
- B. Soak feet in hot water
- C. Wear tight shoes
- D. Cut toenails with scissors
Correct Answer: A
Rationale: Daily foot inspection helps detect early signs of injury or infection in type 2 diabetes, preventing complications like ulcers.
A newborn girl's father expresses concern that the newborn does not have good control of her hands and arms. It is important for the father to realize certain neurological patterns that characterize the newborn:
- A. Mild hypotonia is expected in the upper extremities.
- B. Purposeless, uncoordinated movements of the arms are indicative of neurological dysfunction.
- C. Function progresses in a head-to-toe, proximal-distal fashion.
- D. Asymmetrical movement of the extremities is not unusual and will disappear with maturation of the central nervous system.
Correct Answer: C
Rationale: Term neonates are predominantly in a flexed position with strong active muscle tone that increases. Newborns are slightly hypertonic. Neonatal movements may be jerky and uncoordinated as the neonate works against gravity in contrast to the buoyancy of the amniotic fluid. Jerky movements must be differentiated from the tremors of hypoglycemia, hypocalcemia, and neurological dysfunction. Growth of the newborn progresses in a cephalocaudal, proximal-distal fashion. Knowledge regarding infant development may facilitate parental involvement and infant stimulation. Asymmetrical movements of the extremities are indicative of neurological dysfunction.
The physician of an alcoholic client places him on a low-protein, high-carbohydrate diet. When choosing his menu, the client's best choice from the items below would be:
- A. Liver and onions, macaroni and cheese, tea with sugar
- B. Baked chicken, baked potato with bacon bits, milk
- C. Waffles with butter and honey, orange juice
- D. Cheese omelette with ham and mushrooms, milk
Correct Answer: C
Rationale: Serum ammonia levels can be decreased by restricting dietary protein intake. Waffles, honey, and orange juice are high in carbohydrate and low or completely lacking in protein. Butter, a concentrated fat, will provide extra calories.
The nurse is caring for a client with suspected endometrial cancer.
- A. Frothy vaginal discharge
- B. Thick, white vaginal discharge
- C. Purulent vaginal discharge
- D. Watery vaginal discharge
Correct Answer: D
Rationale: Endometrial cancer often presents with abnormal uterine bleeding, which can manifest as watery vaginal discharge. Frothy discharge is more typical of trichomoniasis, thick white discharge suggests a yeast infection, and purulent discharge indicates infection, none of which are primary symptoms of endometrial cancer.