Nokea
A client has a tracheostomy tube in place. When the nurse suctions the client food particles are noted. What action by the nurse is best?
- A. Elevate the head of the client's bed.
- B. Measure and compare cuff pressures.
- C. Place the client on NPO status.
- D. Request that the client have a swallow study.
Correct Answer: B
Rationale: The correct answer is B: Measure and compare cuff pressures. When food particles are noted during suctioning, it indicates a potential issue with the tracheostomy tube cuff. By measuring and comparing cuff pressures, the nurse can ensure the cuff is properly inflated to prevent aspiration of food particles into the lungs. Elevating the head of the bed (choice A) is a standard practice for preventing aspiration but does not address the specific issue of cuff pressure. Placing the client on NPO status (choice C) is not necessary if the cuff pressure is the main concern. Requesting a swallow study (choice D) may be needed eventually but is not the immediate priority when food particles are already present.
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What is the primary principle involved in the various airway clearance devices used for mobilizing secretions?
- A. Vibration
- B. Inhalation therapy
- C. Chest physiotherapy
- D. Positive expiratory pressure
Correct Answer: D
Rationale: The primary principle involved in airway clearance devices used for mobilizing secretions is positive expiratory pressure, which helps in loosening and moving mucus from the airways.
If his R = 0.8 how much will his arterial pO2 fall?
- A. 85mmHg
- B. 75mmHg
- C. 60mmHg
- D. 50mmHg
Correct Answer: D
Rationale: The correct answer is D (50mmHg). To calculate the fall in arterial pO2, we use the formula: Fall in pO2 = (Initial pO2) - (Initial pO2 x R). If R = 0.8, the fall in pO2 = (100mmHg) - (100mmHg x 0.8) = 100mmHg - 80mmHg = 20mmHg. Therefore, the arterial pO2 will fall by 20mmHg. Among the choices, D (50mmHg) is the closest to the calculated value of 20mmHg, making it the correct answer. Other choices (A, B, C) do not align with the calculated fall in pO2.
A nurse assesses a client's respiratory status. Which information is of highest priority for the nurse to obtain?
- A. Average daily fluid intake
- B. Neck circumference
- C. Height and weight
- D. Occupation and hobbies
Correct Answer: D
Rationale: The correct answer is D: Occupation and hobbies. This is the highest priority information for the nurse to obtain because it can provide crucial insights into potential respiratory risks or exposures (e.g., smoking, exposure to fumes or pollutants). Understanding the client's occupation and hobbies helps the nurse assess the impact on respiratory health and tailor interventions accordingly.
A: Average daily fluid intake is important for overall health but not directly related to respiratory status.
B: Neck circumference may be relevant for assessing airway patency in certain conditions, but occupation and hobbies are more pertinent.
C: Height and weight are important for general health assessment but do not directly impact respiratory status as much as occupation and hobbies.
In teaching a patient with hypertension about controlling the illness the nurse recognizes that?
- A. All patients with elevated BP need drug therapy.
- B. Obese persons must achieve a normal weight to lower BP.
- C. It is not necessary to limit salt in the diet if taking a diuretic.
- D. Lifestyle modifications are needed for all persons with elevated BP.
Correct Answer: D
Rationale: Rationale:
D is correct because lifestyle modifications, such as exercise and diet changes, are essential for managing hypertension. This approach can help lower blood pressure without the need for drug therapy. A is incorrect because not all patients with elevated BP require medication. B is incorrect as weight loss is beneficial but not the only factor in controlling BP. C is incorrect because limiting salt intake remains important even if taking a diuretic.
The home health nurse is making an initial call on a newly diagnosed tuberculosis (TB) patient. The patient lives with his wife and child. Which infection control instructions shouldn't the nurse include in the teaching plan?
- A. Place contaminated tissues in sealable plastic bag.
- B. Take medications exactly as directed.
- C. Implement airborne precautions.
- D. Wash hands frequently.
Correct Answer: C
Rationale: The correct answer is C because TB is transmitted through droplet transmission, not airborne. The nurse should include hand hygiene (D) to prevent spread through contact, proper medication adherence (B) to treat TB effectively, and proper disposal of contaminated materials (A) to prevent spread through fomites. Implementing airborne precautions is not necessary for TB, as it does not remain suspended in the air for long periods.