Nokea
A nurse is caring for a client who has a tracheostomy tube. Upon data collection, the nurse observes the client is restless and hears crackles in the lungs. Which of the following interventions should the nurse take?
- A. Perform suctioning.
- B. Instill saline into the tubing.
- C. Increase the humidification.
- D. Check the cuff pressure.
Correct Answer: A
Rationale: Restlessness and crackles in the lungs suggest secretions in the airway, and suctioning is the appropriate intervention to clear them in a client with a tracheostomy.
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A nurse is collecting data from a client who is taking enoxaparin. The client reports starting the use of dietary supplements. The nurse should report the use of which of the following supplements to the provider?
- A. Ginkgo biloba
- B. Flaxseed powder
- C. Probiotics
- D. Echinacea
Correct Answer: A
Rationale: Ginkgo biloba can increase the risk of bleeding when taken with enoxaparin, an anticoagulant, and should be reported to the provider.
A nurse is reinforcing teaching about ostomy care with a client who has a new colostomy. Which of the following findings should the nurse instruct the client to report to the provider?
- A. Soft, unformed stools
- B. Purplish stoma
- C. Noticeable stool odor
- D. Slight bleeding around the stoma
Correct Answer: B
Rationale: A purplish stoma indicates potential ischemia or poor blood supply, requiring prompt reporting to the provider.
A nurse is reinforcing teaching with a client who is to undergo a bone marrow aspiration. Which of the following statements should the nurse include in the teaching?
- A. You will need to fast for 2 hours before the procedure.
- B. You will have the bone marrow taken from your femur.
- C. You will not receive a local anesthetic agent for this procedure.
- D. I will hold pressure on the site after the procedure.
Correct Answer: D
Rationale: Holding pressure on the site post-procedure prevents bleeding, a standard part of bone marrow aspiration care.
A nurse is reinforcing teaching with a 30-year-old client who is concerned about cervical cancer. Which of the following statements should the nurse make?
- A. Cervical cancer screenings should begin at age 40
- B. Plan to continue cervical cancer screenings for the rest of your life.
- C. You should get a Papanicolaou (Pap) test and human papillomavirus test every 5 years.
- D. If you are immunized against human papillomavirus, you don't need cervical cancer screenings.
Correct Answer: C
Rationale: For a 30-year-old, Pap and HPV testing every 5 years is recommended per current guidelines, making this the correct statement.
A nurse is collecting data from a client who has a newly placed colostomy. Which of the following findings should indicate to the nurse the client has accepted their new altered body image?
- A. Prefers not to look at the stoma site
- B. Participates in performing ostomy care
- C. Denies feelings of sadness about the ostomy
- D. Accepts that sexual activity will decrease
Correct Answer: B
Rationale: Participating in ostomy care demonstrates acceptance and adaptation to the altered body image.