Nokea
A client comes to the clinic with a bloody nose. Which instruction is most appropriate?
- A. Sit up with your head tilted forward. Grasp the soft part of your nose firmly between your thumb and forefinger.'
- B. Lay down and tilt your head backward. Grasp the end of your nose between your fingers.'
- C. Sit up and lean backwards. Put pressure on the side of your nose with your hand.'
- D. Lie down with your head lower than your feet. Grasp as much of your nose as possible between your fingers.'
Correct Answer: A
Rationale: Sitting with the head tilted forward and grasping the soft part of the nose prevents aspiration of blood and effectively stops bleeding.
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The client diagnosed with oat cell carcinoma of the lung tells the nurse, 'I am so tired of all this. I might as well just end it all.' Which statement should be the nurse's first response?
- A. Say, 'This must be hard for you. Would you like to talk?'
- B. Tell the HCP of the client's statement.
- C. Refer the client to a social worker or spiritual advisor.
- D. Find out if the client has a plan to carry out suicide.
Correct Answer: A
Rationale: Acknowledging feelings and offering to talk (A) opens communication for suicidal ideation. Notifying HCP (B), referring (C), and assessing plans (D) follow.
A thoracentesis was performed on an adult client. After the procedure, the client has hemoptysis and a pulse of 80, respirations of 28, and temperature of 99°F. Which of these is of greatest concern to the nurse?
- A. Hemoptysis
- B. Respirations of 28
- C. Pulse of 80
- D. Temperature of 99°F
Correct Answer: A
Rationale: Hemoptysis is the only abnormal finding and indicates potential bleeding or lung injury, which is of greatest concern post-thoracentesis. The other vital signs are within normal ranges for someone who has undergone an invasive procedure.
While the nurse is suctioning a tracheostomy tube, the client starts to cough. What is the best action for the nurse to take?
- A. Suction deeper to pick up secretions
- B. Gently withdraw suction tubing to allow suction or coughing out of mucus
- C. Remove the suction as quickly as possible
- D. Put the suction tube in and out several times to pick up secretions
Correct Answer: C
Rationale: Removing the suction quickly allows the client to cough out mucus naturally, preventing irritation or trauma.
The nurse is preparing the client diagnosed with laryngeal cancer for a laryngectomy in the morning. Which intervention is the nurse's priority?
- A. Take the client to the intensive care unit for a visit.
- B. Explain that the client will need to ask for pain medication.
- C. Demonstrate the use of an antiembolism hose.
- D. Find out if the client can read and write.
Correct Answer: D
Rationale: Literacy (D) ensures post-laryngectomy communication (e.g., writing), a priority. ICU visit (A), pain requests (B), and TED hose (C) are secondary.
When suctioning a client with a tracheostomy, when is the best time to occlude the vent on the suction catheter?
- A. Before inserting the catheter
- B. When inside the inner cannula
- C. While withdrawing the catheter
- D. When the client begins coughing
Correct Answer: C
Rationale: Occluding the vent while withdrawing the catheter applies suction to remove secretions effectively.