Nokea
A client is diagnosed with Mycobacterium tuberculosis. He is placed in respiratory isolation, intubated, and receives mechanical ventilation. When performing suctioning, the nurse should:
- A. Suction for a maximum of 20 seconds
- B. Hyperoxygenate before and after suctioning
- C. Suction for a maximum of 30 seconds
- D. Maintain clean technique during suctioning
Correct Answer: B
Rationale: Supplemental O2 should be administered before and after suctioning to reduce hypoxia.
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Which of the following is an expected finding in a child with osteogenesis imperfecta?
- A. Blue sclera
- B. Hutchinson's teeth
- C. Anisocoria
- D. Pectus excavatum
Correct Answer: A
Rationale: Blue sclera is a hallmark of osteogenesis imperfecta due to thin connective tissue in the eyes. Hutchinson’s teeth are associated with congenital syphilis anisocoria is unequal pupil size and pectus excavatum is a chest deformity not specific to this condition.
The nurse is caring for a client with a diagnosis of rheumatoid arthritis who is receiving methotrexate. Which laboratory value would be most concerning?
- A. WBC 4,000/mm3
- B. Platelet count 150,000/mm3
- C. Hemoglobin 13 g/dL
- D. Serum creatinine 1.2 mg/dL
Correct Answer: A
Rationale: Methotrexate can cause bone marrow suppression. A WBC of 4,000/mm3 (A) indicates leukopenia, increasing infection risk, and is most concerning. Platelets (B), hemoglobin (C), and creatinine (D) are within normal limits.
The nurse is teaching a client with a history of kidney stones about dietary modifications. The nurse should tell the client to:
- A. Increase fluid intake
- B. Avoid all calcium
- C. Consume high-oxalate foods
- D. Reduce protein intake
Correct Answer: A
Rationale: Increasing fluid intake dilutes urine, reducing the risk of kidney stone formation.
A client with a history of renal failure is admitted with complaints of shortness of breath. The nurse should expect the client to have:
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: A
Rationale: Renal failure impairs acid excretion, leading to metabolic acidosis, which can cause compensatory hyperventilation and shortness of breath.
In working with mental health clients who are prescribed medication that must be taken on a routine basis, it is important for education to begin when the drug therapy is initiated. One of the first steps in the teaching process is to:
- A. Explain the side effects of the medication
- B. Discuss the danger of overmedication
- C. Distribute written material to supplement verbal instructions
- D. Explore the client's perception regarding medication therapy
Correct Answer: D
Rationale: (A, B, C) The nurse must first obtain information regarding the client's perception of the medication regimen. The first step in the teaching process is to determine the client's perception.