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A nurse is caring for a client immediately following intubation with an endotracheal (ET) tube. Which of the following methods should the nurse identify as the most reliable for verifying placement of the ET tube?
- A. Observing for symmetrical chest rise and fall
- B. Auscultating bilateral breath sounds
- C. Using an end-tidal COâ‚‚ detector
- D. Checking for condensation in the ET tube
Correct Answer: C
Rationale: The correct answer is C: Using an end-tidal CO2 detector. This method is the most reliable for verifying ET tube placement because it directly measures the presence of CO2 in exhaled breath, confirming that the tube is in the trachea. This is crucial to prevent inadvertent esophageal intubation. Observing for symmetrical chest rise and fall (A) can be misleading as it can occur even with esophageal intubation. Auscultating bilateral breath sounds (B) can also be unreliable as breath sounds may be heard even if the tube is in the esophagus. Checking for condensation in the ET tube (D) is not a reliable method for verifying placement as condensation can occur regardless of tube placement.
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A nurse is planning preventative strategies for a client who is at risk for pressure injuries. Which of the following actions should the nurse include in the plan?
- A. Apply moisturizer to damp skin after bathing.
- B. Massage bony prominences to improve circulation.
- C. Use cornstarch powder to keep skin dry.
- D. Position the client at a 90-degree angle in bed.
Correct Answer: A
Rationale: The correct answer is A: Apply moisturizer to damp skin after bathing. Moisturizing helps maintain skin integrity and hydration, reducing the risk of pressure injuries. When skin is damp, it is more receptive to hydration, which can prevent dryness and breakdown. Applying moisturizer also helps to maintain the skin's natural barrier function. Massaging bony prominences (choice B) can actually increase the risk of pressure injuries by causing friction and shearing forces. Using cornstarch powder (choice C) can lead to moisture buildup and increase the risk of skin breakdown. Positioning the client at a 90-degree angle in bed (choice D) is not a recommended preventive strategy for pressure injuries.
A nurse is assessing a client who has suspected appendicitis. Which of the following manifestations should the nurse expect? (Select all that apply.)
- A. Right lower quadrant pain
- B. Rebound tenderness
- C. Nausea and vomiting
- D. Elevated blood glucose
- E. Hypotension
Correct Answer: A, B, C
Rationale: The correct manifestations for suspected appendicitis are A, B, and C. A is correct as appendicitis typically presents with right lower quadrant pain due to inflammation of the appendix. B is correct as rebound tenderness, which is pain upon release of pressure on the abdomen, is a classic sign of appendicitis. C is correct as nausea and vomiting are common symptoms due to irritation of the gastrointestinal tract. D and E are incorrect as elevated blood glucose and hypotension are not commonly associated with appendicitis.
A nurse is caring for a client who is receiving peritoneal dialysis. Which of the following actions should the nurse take?
- A. Report cloudy dialysate drainage to the provider.
- B. Lower the drainage bag below the level of the abdomen.
- C. Encourage fluid intake of 3L per day.
- D. Use sterile gloves only when removing the catheter.
Correct Answer: A
Rationale: The correct answer is A: Report cloudy dialysate drainage to the provider. Cloudy dialysate drainage can indicate infection, leading to peritonitis. The nurse should report this immediately for further evaluation and treatment to prevent complications. Lowering the drainage bag below the abdomen (B) can cause backflow, increasing the risk of contamination. Encouraging fluid intake of 3L per day (C) is a general recommendation but not specific to peritoneal dialysis. Using sterile gloves only when removing the catheter (D) is incorrect as sterile technique is required during all catheter manipulations in peritoneal dialysis.
A nurse is assessing a clients ECG strip and notes an irregular heart rate of 98/min with no clear P waves. Which of the following cardiac dysrhythmias should the nurse document?
- A. Sinus bradycardia
- B. Atrial fibrillation
- C. Ventricular tachycardia
- D. First-degree heart block
Correct Answer: B
Rationale: The correct answer is B: Atrial fibrillation. In atrial fibrillation, the heart rate is irregular and fast (98/min), and there are no clear P waves on the ECG strip, which aligns with the findings in the scenario. Atrial fibrillation is characterized by chaotic electrical activity in the atria, leading to an irregular heart rate. Sinus bradycardia (A) is characterized by a slow heart rate with normal P waves. Ventricular tachycardia (C) is a fast heart rhythm originating in the ventricles with distinct QRS complexes. First-degree heart block (D) is identified by a prolonged PR interval but should still have clear P waves. Other choices are not relevant. In this case, the absence of clear P waves and irregular heart rate point towards atrial fibrillation as the correct dysrhythmia to document.
A nurse is caring for a client who has end-stage kidney disease. The clients adult child asks the nurse about becoming a living kidney donor for their parent. Which of the following conditions in the childs medical history should the nurse identify as a contraindication to the procedure?
- A. Amputation
- B. Osteoarthritis
- C. Hypertension
- D. Primary glaucoma
Correct Answer: C
Rationale: The correct answer is C: Hypertension. Hypertension is a contraindication for kidney donation due to the increased risk of kidney disease and complications post-donation. High blood pressure can impair kidney function and increase the risk of cardiovascular events. Amputation (A), osteoarthritis (B), and primary glaucoma (D) are not contraindications for kidney donation as they do not directly impact kidney function or pose significant risks for the donor.