Nokea
A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following actions should the nurse take?
- A. Suction the tube every 2 hr.
- B. Secure the tube to the client's face.
- C. Monitor the client's cuff pressure daily.
- D. Reposition the client every 4 hr.
Correct Answer: B
Rationale: Securing the tube prevents dislodgement, ensuring airway safety. Suctioning is as needed, cuff pressure checks are frequent, and repositioning is every 2 hours.
You may also like to solve these questions
A nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions should the nurse take?
- A. Check the ventilator settings every 8 hr.
- B. Suction the endotracheal tube every 4 hr.
- C. Monitor the client's oxygen saturation continuously.
- D. Administer a bronchodilator every 12 hr.
Correct Answer: C
Rationale: Continuous oxygen saturation monitoring ensures adequate ventilation. Settings checks, suctioning, and bronchodilators depend on specific needs, not fixed schedules.
A nurse is reinforcing teaching with a client who has a new prescription for atorvastatin. Which of the following statements should the nurse include?
- A. You should take this medication in the morning.
- B. You might experience muscle pain while taking this medication.
- C. You need to avoid eating grapefruit while taking this medication.
- D. You should stop taking this medication if you feel dizzy.
Correct Answer: B
Rationale: Atorvastatin can cause myopathy, so muscle pain should be monitored. It's taken at night, grapefruit interaction is minimal, and dizziness doesn't warrant stopping.
A nurse is caring for a client who has a new prescription for heparin. Which of the following laboratory values should the nurse monitor?
- A. Potassium
- B. Hemoglobin
- C. Partial thromboplastin time (PTT)
- D. Blood urea nitrogen (BUN)
Correct Answer: C
Rationale: Heparin's anticoagulant effect is monitored via PTT to ensure therapeutic dosing. Potassium, hemoglobin, or BUN aren't directly affected by heparin.
A nurse is reinforcing teaching with new parents about car seat safety. Which of the following instructions should the nurse include?
- A. Keep the airbag on if the car seat is in the front seat.
- B. Position the car seat at a 90° angle.
- C. Put a small cushion under the newborn's head for support.
- D. Place the shoulder harnesses at the level of the infant's shoulders.
Correct Answer: D
Rationale: Shoulder harnesses at shoulder level ensure a secure fit, enhancing safety. Airbags should be off for front-seat car seats, the angle should be 45°, and cushions can disrupt proper positioning.
A nurse is caring for a client who is postoperative following an appendectomy. Which of the following findings should the nurse report to the provider?
- A. The client reports pain at the incision site.
- B. The client's temperature is 38.1°C (100.5°F).
- C. The client has not had a bowel movement since surgery.
- D. The client's incision is intact with minimal drainage.
Correct Answer: B
Rationale: A temperature of 38.1°C suggests possible infection, requiring reporting. Pain, no bowel movement, or minimal drainage are expected post-appendectomy.