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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. Check the tube cuff pressure every 8 hours.
- B. Suction the tube every 4 hours.
- C. Reposition the tube every 12 hours.
- D. Clean the tube with alcohol-based solution.
Correct Answer: A
Rationale: Checking the tube cuff pressure every 8 hours ensures it remains within a safe range to prevent tracheal damage or air leaks.
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A nurse is caring for a client who has a new diagnosis of achalasia. Which of the following findings should the nurse expect?
- A. Dysphagia
- B. Weight gain
- C. Bradycardia
- D. Hypotension
Correct Answer: A
Rationale: Dysphagia, difficulty swallowing, is a hallmark symptom of achalasia due to esophageal motility issues.
A nurse is reinforcing teaching with a client who has a new prescription for insulin glargine. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will take this insulin before meals.
- B. I will rotate injection sites.
- C. I will shake the vial before drawing up the insulin.
- D. I will store the insulin in the freezer.
Correct Answer: B
Rationale: Rotating injection sites prevents lipodystrophy and ensures consistent insulin absorption.
A nurse is reinforcing teaching with a client who has a new prescription for a contraceptive patch. Which of the following instructions should the nurse include?
- A. Apply the patch to the same site each week.
- B. Change the patch every 2 weeks.
- C. Apply the patch to the lower abdomen.
- D. Store the patch in the refrigerator.
Correct Answer: C
Rationale: Applying the contraceptive patch to the lower abdomen (or other recommended sites) ensures effective hormone delivery.
A nurse is reinforcing teaching with a client who is scheduled for a cardiac catheterization. Which of the following instructions should the nurse include?
- A. Fast for 6 hours before the procedure.
- B. Drive yourself home after the procedure.
- C. Expect to stay overnight routinely.
- D. Avoid lying flat after the procedure.
Correct Answer: A
Rationale: Fasting for 6 hours before a cardiac catheterization reduces the risk of aspiration during sedation.
A nurse is caring for a client who is postoperative following abdominal surgery and has a wound evisceration. Which of the following actions should the nurse take?
- A. Cover the wound with sterile, saline-soaked gauze.
- B. Hold gentle, direct pressure on the protruding organ.
- C. Place the client's knees in an extended position.
- D. Raise the head of the bed to a 45° angle.
Correct Answer: A
Rationale: Covering the wound with sterile, saline-soaked gauze is correct. Evisceration occurs when abdominal contents protrude through a surgical wound. To prevent drying and further tissue damage, the nurse should immediately cover the exposed organs with sterile gauze moistened with saline to maintain moisture and reduce infection risk.