Nokea
A client attached to mechanical ventilation suddenly becomes restless and pulls out the tracheostomy tube. Which is the nurse's priority intervention?
- A. Prepare for reintubation.
- B. Call the health care provider.
- C. Call the rapid response team.
- D. Check the client for spontaneous breathing.
Correct Answer: D
Rationale: If a tracheostomy tube is dislodged, checking for spontaneous breathing (D) is the priority to assess airway patency and oxygenation need. Preparing for reintubation (A) or calling teams (B, C) follows. D is correct. Rationale: Assessing breathing determines if immediate reinsertion or oxygenation is urgent, guiding next steps per respiratory emergency standards, ensuring patient stability first.
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A woman who is six months pregnant is seen in antepartal clinic. She states she is having trouble with constipation. To minimize this condition, the nurse should instruct her to
- A. Increase her fluid intake to three liters/day
- B. Request a prescription for a laxative from her physician
- C. Stop taking iron supplements
- D. Take two tablespoons of mineral oil daily
Correct Answer: A
Rationale: Increased fluid intake helps prevent constipation by softening stool.
Which of the following statement is TRUE about tertiary care?
- A. Provided by general practitioners
- B. Focuses on health promotion
- C. Highly specialized care
- D. All of the above
Correct Answer: C
Rationale: Tertiary care is highly specialized (C), per system e.g., surgery, rehab. Not by GPs (A), not promotion (B), not all (D) advanced focus. C truly defines tertiary's complexity, making it correct.
The nurse gave Mr. Gary his medication as planned. This is an example of?
- A. Implementation
- B. Planning
- C. Evaluation
- D. Assessment
Correct Answer: A
Rationale: Giving medication as planned is implementation (A) executing care, per process. Planning (B) sets, evaluation (C) assesses, assessment (D) gathers not action-specific. A fits intervention delivery, making it correct.
The nurse must verify the client's identity before administration of medication. Which of the following is the safest way to identify the client?
- A. Ask the client his name
- B. Check the client's identification band
- C. State the client's name aloud and have the client repeat it
- D. Check the room number
Correct Answer: B
Rationale: The ID band is the most reliable method, ensuring accuracy even if the client is confused.
Which of the following condition has an increased risk of for developing hyperkalemia?
- A. Crohn's disease
- B. Cushing's disease
- C. Chronic heart failure
- D. End-stage renal disease
Correct Answer: D
Rationale: End-stage renal disease impairs potassium excretion, causing hyperkalemia as kidneys fail to filter excess. Crohn's affects absorption, Cushing's alters cortisol, and heart failure impacts circulation not potassium directly. Nurses monitor levels in renal patients, adjusting diet or dialysis to prevent arrhythmias or muscle issues from high potassium, a common complication.