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A nurse is caring for a client who requires nasotracheal suctioning. Identify the sequence the nurse should follow to perform suctioning.
- A. Rinse the catheter to remove secretions.
- B. Insert the catheter during the client's inspiration.
- C. Turn on the suction and set the pressure.
- D. Don sterile gloves
- E. Apply sunction while rotating catheter
Correct Answer: D,C,B,E,A
Rationale: Correct Order: D, C, B, E, A
Rationale:
1. Don sterile gloves (D): Ensures infection control and prevents cross-contamination.
2. Turn on suction and set pressure (C): Prepares equipment and ensures proper functioning.
3. Insert catheter during client's inspiration (B): Reduces risk of inducing hypoxia.
4. Apply suction while rotating catheter (E): Maximizes removal of secretions.
5. Rinse catheter to remove secretions (A): Ensures cleanliness and prevents re-introduction of secretions.
Summary of Incorrect Choices:
- F and G are not applicable in this sequence.
- Inserting the catheter during inspiration (B) is correct, not during expiration.
- Rinsing the catheter (A) is done after suctioning, not before.
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The nurse is planning care for the client. Which of the following prescriptions should the nurse anticipate the provider to prescribe?
- A. Limit alcohol intake to two drinks per day.
- B. Keep daily fat intake to less than 35%.
- C. Administer an antibiotic medication.
- D. Place on 2,300 mg sodium diet.
- E. Administer an antihypertensive medication.
- F. Limit foods high in potassium.
Correct Answer: A,D,E
Rationale: The correct answers are A, D, and E. A - Limiting alcohol intake reduces the risk of adverse health effects. D - A 2,300 mg sodium diet is beneficial for managing blood pressure. E - Antihypertensive medication helps control high blood pressure. B and F are not directly related to planning care for the client. C may not be necessary unless there is an infection present.
A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority?
- A. Request that a respiratory therapist discuss the technique for incentive spirometry with the client.
- B. Determine the reasons why the client is refusing to use the incentive spirometer.
- C. Document the client's refusal to participate in health restorative activities.
- D. Administer a pain medication to the client.
Correct Answer: B
Rationale: The correct answer is B: Determine the reasons why the client is refusing to use the incentive spirometer. The priority is to assess the client's reasons for refusal to address any barriers preventing compliance, such as fear, pain, or lack of understanding. Understanding the client's perspective can help tailor interventions and address concerns effectively. Requesting a respiratory therapist (choice A) or administering pain medication (choice D) can be secondary once the client's reasons are identified. Simply documenting the refusal (choice C) without addressing the underlying cause does not promote client-centered care.
A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?
- A. A client who is scheduled for a procedure in 1 hr.
- B. A client who received a pain medication 30 min ago for postoperative pain.
- C. A client who was just given a glass of orange juice for a low blood glucose level.
- D. A client who has 100 mL of fluid remaining in his IV bag.
Correct Answer: C
Rationale: The nurse should assess client C first because low blood glucose levels can lead to serious complications if not addressed promptly. Hypoglycemia can result in altered mental status, seizures, and even coma. Assessing and addressing this client's low blood glucose level is a priority to prevent further deterioration.
Clients A, B, and D do not have immediate life-threatening conditions that require urgent assessment compared to client C. Client A, scheduled for a procedure in 1 hr, can be assessed after client C. Client B, who received pain medication 30 min ago, would have some time before needing reassessment. Client D, with 100 mL of fluid remaining in the IV bag, can also wait as long as there is no indication of the client being dehydrated or in need of immediate intervention.
A nurse is caring for a client who has acute glomerulonephritis. Which of the following findings should the nurse expect?
- A. Oliguria
- B. Hypotension
- C. Weight loss
- D. Hematuria
Correct Answer: D
Rationale: The correct answer is D: Hematuria. In acute glomerulonephritis, inflammation of the glomeruli causes blood to leak into the urine, resulting in hematuria. This is a classic sign of the condition. Oliguria (A) is decreased urine output, not typically associated with glomerulonephritis. Hypotension (B) is not a common finding as fluid retention is more likely. Weight loss (C) is not a typical symptom, as fluid retention and edema are more common. In summary, hematuria is the hallmark sign of acute glomerulonephritis, distinguishing it from the other choices.
A nurse is teaching a client who has a new diagnosis of diabetes mellitus about foot care. Which of the following instructions should the nurse include in the teaching?
- A. Soak feet twice daily.
- B. Round the edges of toenails when trimming.
- C. Use moisturizing lotion between the toes.
- D. Wear clean cotton socks every day.
Correct Answer: D
Rationale: The correct answer is D: Wear clean cotton socks every day. This instruction is essential for proper foot care in diabetes mellitus as it helps prevent fungal infections and keeps feet dry. Soaking feet twice daily (choice A) can lead to skin breakdown. Rounding the edges of toenails (choice B) can increase the risk of ingrown toenails. Using moisturizing lotion between the toes (choice C) can create a moist environment, fostering fungal growth. Therefore, wearing clean cotton socks daily is the most appropriate instruction to promote foot health in a client with diabetes mellitus.