Nokea
A nurse is caring for a client who has a tracheostomy and requires suctioning. Which of the following actions should the nurse take?
- A. Suction for no longer than 10 to 15 seconds
- B. Use a clean catheter each time
- C. Apply suction while inserting the catheter
- D. Hyperoxygenate the client after suctioning
Correct Answer: A
Rationale: Tracheostomy suctioning clears secretions but risks hypoxia if prolonged. Suctioning for no longer than 10-15 seconds limits oxygen deprivation per guidelines allowing recovery between passes, critical for a client reliant on a patent airway. Using a clean catheter each time compromises sterility, risking infection sterile is standard. Applying suction while inserting spreads secretions, clogging the tube, while hyperoxygenation post-suctioning helps but pre-suctioning is key to preload oxygen. The time limit balances efficacy and safety, reflecting the nurse's skill in preventing hypoxia or trauma, ensuring effective airway management in a procedure vital for respiratory stability.
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As a member of a hospital committee, you advocate for a policy that allows staff nurses to request additional staffing during unexpected increases in patient acuity. Your advocacy reflects concerns about:
- A. Staff satisfaction
- B. Patient safety
- C. Cost containment
- D. Staff authority
Correct Answer: B
Rationale: Pushing for staffing boosts during acuity spikes like a trauma surge prioritizes patient safety, ensuring care matches need, cutting risks like errors or delays. Satisfaction may rise, costs shift, and authority isn't the focus safety is. On the committee, you address workload stress, as in fall or error trends, aligning with nursing's duty to protect patients, a proactive policy to maintain quality under pressure.
A nurse is assessing a 70-year-old client. What gastrointestinal abnormality does the nurse recognize is common in clients of this age?
- A. Diverticulosis
- B. Intestinal obstructions
- C. Appendicitis
- D. Diverticulitis
Correct Answer: A
Rationale: In a 70-year-old, diverticulosis pouches in the colon is common, unlike obstructions, appendicitis, or diverticulitis, which is inflammation of those pouches. Aging slows motility and weakens walls, raising diverticulosis risk; it's often asymptomatic but prevalent. Obstructions or appendicitis aren't age-specific, and diverticulitis requires infection. Leadership means knowing this imagine screening an elder with vague discomfort; recognizing diverticulosis guides diet advice, preventing complications. This reflects nursing's role in age-appropriate care, enhancing safety and health in geriatric populations effectively.
The nurse is assessing a client with suspected dehydration. Which finding supports this diagnosis?
- A. Poor skin turgor
- B. Increased urine output
- C. Bounding pulses
- D. Moist mucous membranes
Correct Answer: A
Rationale: In suspected dehydration, poor skin turgor supports it, not high output, strong pulses, or moist membranes (fluid excess signs). Low volume tents skin turgor flags need for fluids. Leadership notes this imagine dryness; it guides rehydration, aligning with hydration care effectively.
A client with a history of gastroesophageal reflux disease is prescribed pantoprazole. Which instruction should the nurse include?
- A. Take the medication before meals
- B. Take it only when heartburn occurs
- C. Increase intake of spicy foods
- D. Stop the medication once symptoms improve
Correct Answer: A
Rationale: For pantoprazole in GERD, take before meals, not PRN, spicy, or stop. PPIs block acid pre-meal PRN's ineffective, spices worsen, stopping risks rebound. Leadership teaches this imagine relief; it ensures efficacy, aligning with GI care effectively.
A nurse is preparing to attend a care plan conference for a client who has severe burns. Which of the following criteria should the nurse identify as part of an effective conference?
- A. The nurse leads all discussions
- B. Other health care professionals are in attendance at the conference
- C. The client is excluded from planning
- D. Only nursing goals are set
Correct Answer: B
Rationale: An effective care plan conference for a severe burns client requires interdisciplinary input due to the condition's complexity skin integrity, infection risk, mobility, nutrition, and psychological impact. Identifying that other healthcare professionals (e.g., physical therapists, dieticians, psychologists) attend ensures diverse expertise shapes a comprehensive plan, setting realistic, client-centered goals for recovery. The nurse leading all discussions limits collaboration, while excluding the client ignores their input and autonomy, reducing efficacy. Focusing only on nursing goals neglects broader needs like rehabilitation or dietary support. Multidisciplinary attendance fosters holistic planning, leverages specialized knowledge, and enhances outcomes, aligning with best practices for complex cases like burns, where teamwork drives success.