Nokea
A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client may need suctioning?
- A. Drowsiness
- B. Complaint of nausea
- C. Pulse rate of 82
- D. Restlessness
Correct Answer: D
Rationale: Restlessness. Restlessness, increased heart and respiratory rates, and noisy expiration suggest hypoxia and are indications for suctioning.
You may also like to solve these questions
An 86 year-old nursing home resident who has impaired mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next?
- A. Add a thickening agent to the fluids
- B. Check the client's gag reflex
- C. Feed the client only solid foods
- D. Increase the rate of intravenous fluids
Correct Answer: B
Rationale: Check the client's gag reflex. When a new problem emerges, the nurse should perform appropriate assessment so that suitable nursing interventions can be planned. Aspiration pneumonia follows aspiration of material from the mouth into the trachea and finally the lung. A loss or an impairment of the protective cough reflex can result in aspiration.
The nurse learns that the hospitalized client has a history of chronic hepatitis C. Which precaution should the nurse plan to implement?
- A. Airborne
- B. Contact
- C. Droplet
- D. Standard
Correct Answer: D
Rationale: D: Standard precautions are sufficient for hepatitis C, which is transmitted via blood and body fluids. A, B, C are unnecessary as hepatitis C is not airborne or droplet-transmitted.
Which of these statements from clients who call the community health clinic would suggest the need for a same-day appointment to be seen by the health care provider?
- A. I started my period and now my urine has turned bright red'
- B. I am a diabetic and today I have been going to the bathroom every hour'
- C. I was started on medicine yesterday for a urine infection. Now my lower belly hurts when I go to the bathroom'
- D. I went to the bathroom and my urine looked very red and it didn't hurt when I went'
Correct Answer: D
Rationale: With this description of symptoms this client needs to be seen that day since painless gross hematuria is closely associated with bladder cancer. The other complaints can be handled over the phone.
A college student is hospitalized with meningococcal meningitis after being seen in the campus clinic. What is the nurse's responsibility to the campus community regarding this diagnosis?
- A. Quarantine all students and faculty remaining on the campus
- B. E-mail school administrators with the names of infected students
- C. Identify all individuals who have had close contact with the student
- D. Ensure that everyone on campus receive prophylactic antibiotics
Correct Answer: C
Rationale: C: Identifying close contacts allows targeted prophylaxis, preventing spread. A: Quarantine is excessive. B: Sharing names violates privacy. D: Prophylaxis is only for close contacts.
After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is
- A. abdominal x-ray
- B. auscultation
- C. flushing tube with saline
- D. aspiration for gastric contents
Correct Answer: A
Rationale: abdominal x-ray. Placement should be verified by radiograph to determine that the tube is in the stomach or intestine rather than in the airways.