Nokea
A female adult client has a tracheostomy but doesn't require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for:
- A. 15 to 60 seconds.
- B. 5 to 20 minutes.
- C. 30 to 40 minutes.
- D. 45 to 60 minutes.
Correct Answer: B
Rationale: The correct answer is B: 5 to 20 minutes. Plugging the tracheostomy tube for this duration allows the client to gradually adapt to breathing without the assistance of the tube. Initially, the client may experience increased respiratory effort, which helps improve lung function. Plugging the tube for too short a time (A) may not provide enough challenge for the client, while plugging it for too long (C, D) may cause distress or potential complications due to lack of oxygen. Therefore, the optimal time frame of 5 to 20 minutes ensures a safe and effective weaning process for the client.
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A nurse auscultates a harsh hollow sound over a client's trachea and larynx. What action would the nurse take first?
- A. Document the findings.
- B. Administer oxygen therapy.
- C. Position the client in high-Fowler position.
- D. Administer prescribed albuterol.
Correct Answer: A
Rationale: The correct action is to document the findings first because the harsh hollow sound over the trachea and larynx could indicate a potential issue with the airway or respiratory function. Documenting the findings allows for accurate communication with other healthcare providers and helps track changes in the client's condition. Administering oxygen therapy or albuterol should not be done without further assessment or orders from a healthcare provider. Positioning the client in high-Fowler position may not be the priority until a more thorough assessment is completed.
The most common preventive drug therapy for tuberculosis is:
- A. Prednisone.
- B. Isoniazid.
- C. Gamma globulin.
- D. Aminophylline.
Correct Answer: B
Rationale: The correct answer is B: Isoniazid. Isoniazid is the most common preventive drug therapy for tuberculosis due to its effectiveness in treating latent TB infections. It works by killing the bacteria that cause TB. Prednisone is a steroid and not used as a preventive therapy for TB. Gamma globulin is used for immune deficiency disorders, not TB prevention. Aminophylline is a bronchodilator used for asthma, not TB prevention. In summary, isoniazid is the preferred choice for TB prevention due to its specific antimycobacterial action, while the other options are unrelated or ineffective for this purpose.
Inflammation of the lung covering causing severe chest pain is
- A. Emphysema
- B. Pleurisy
- C. Asphyxia
- D. Hypoxia
Correct Answer: B
Rationale: The correct answer is B: Pleurisy. Pleurisy is the inflammation of the lung covering (pleura), leading to severe chest pain. Emphysema (A) is a chronic lung disease characterized by damaged air sacs. Asphyxia (C) is a condition of inadequate oxygen supply. Hypoxia (D) is a state of low oxygen levels in tissues. Pleurisy is the best fit as it directly relates to inflammation of the lung covering and severe chest pain.
A nurse cares for a client who had a partial laryngectomy 10 days ago. The client states that all food tastes bland. How would the nurse respond?
- A. I will consult the speech therapist to ensure you are swallowing properly.
- B. This is normal after surgery. What types of food do you like to eat?
- C. I will ask the dietitian to change the consistency of the food in your diet.
- D. Replacement of protein, calories, and water is very important after surgery.
Correct Answer: B
Rationale: Step 1: Acknowledge client's concern about bland taste.
Step 2: Validate normalcy post-laryngectomy.
Step 3: Assess client's food preferences for individualized care.
Step 4: Encourage open communication for effective care plan.
Step 5: Addressing the issue holistically promotes client-centered care.
Summary:
- A: Focuses on swallowing, not taste.
- C: Addresses food consistency, not taste.
- D: Important but not directly related to client's concern.
When obtaining a health history from a 76-year-old patient with suspected CAP, what does the nurse expect the patient or caregiver to report?
- A. Confusion
- B. An abrupt onset of fever and chills
- C. A recent loss of consciousness
- D. A gradual onset of headache and sore throat
Correct Answer: B
Rationale: In patients with Community-Acquired Pneumonia (CAP), an abrupt onset of fever and chills is a common symptom to expect. This is due to the rapid inflammatory response in the lungs. Confusion, loss of consciousness, and gradual headache and sore throat are less likely to be reported initially.