Nokea
A nurse is collecting data about a client's pulmonary system. While auscultating the client's lungs, the nurse hears continuous gurgling, low-pitched sounds over the trachea and bronchi. Which of the following terms should the nurse use to document this finding?
- A. Rhonchi
- B. Crackles
- C. Wheezing
- D. Friction rub
Correct Answer: A
Rationale: The correct answer is A: Rhonchi. Rhonchi are continuous, low-pitched gurgling sounds heard over the trachea and bronchi. This finding indicates the presence of secretions or mucus in the larger airways. Crackles (B) are discontinuous, popping sounds heard during inspiration and indicate fluid in the alveoli. Wheezing (C) is a high-pitched whistling sound that occurs when air flows through narrowed airways. Friction rub (D) is a grating or rubbing sound heard during inspiration and expiration, caused by inflammation of the pleural surfaces. The other choices are not consistent with the described findings.
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A nurse is caring for a client who ingested a poison and is now having seizures. Which of the following is the priority action the nurse should take?
- A. Maintain the patency of the client's airway.
- B. Identify the poison the client ingested.
- C. Measure the client's blood pressure.
- D. Position the client on her side.
Correct Answer: A
Rationale: Airway patency is the priority during seizures to prevent aspiration and ensure adequate oxygenation.
A nurse is reinforcing teaching with a 40-year-old female client about preventive health screenings. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should have my skin checked every 5 years for cancer.
- B. I will need to have a mammogram every year now.
- C. I should have my first colonoscopy when I turn 65.
- D. I will be checked for uterine cancer every 2 years.
Correct Answer: B
Rationale: The correct answer is B: "I will need to have a mammogram every year now." This statement indicates an understanding of preventive health screenings for a 40-year-old female. Mammograms are recommended annually starting at age 40 to screen for breast cancer. Choice A is incorrect as skin checks for cancer should be more frequent than every 5 years. Choice C is incorrect as the first colonoscopy is recommended at age 50, not 65. Choice D is incorrect as uterine cancer screening is typically not done every 2 years.
A nurse is assisting with the development of a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse contribute to the plan? (Select all that apply)
- A. Keep a night light on in the client's room and bathroom.
- B. Keep the bed at a comfortable working height.
- C. Lock the wheels on beds and wheelchairs during transfers.
- D. Place the bedside table within the client's reach.
- E. Administer a sedative at bedtime.
Correct Answer: A,C,D
Rationale: The correct actions to contribute to the fall prevention plan are A, C, and D. A night light can help the client see clearly at night, reducing the risk of tripping. Locking the wheels on beds and wheelchairs ensures stability during transfers. Placing the bedside table within reach promotes independence and prevents falls from reaching for items. Choice B is incorrect as bed height doesn't directly impact fall risk. Choice E, administering a sedative, can increase fall risk due to drowsiness.
A nurse is preparing to suction the airway of a client who has a tracheostomy. Identify the sequence of actions the nurse should take after performing hand hygiene.
- A. Adjust the suction to 120 to 150 mm Hg.
- B. Apply intermittent suction while rotating the catheter.
- C. Don sterile gloves.
- D. Check the function of the suction catheter.
- E. Insert the catheter without suction.
- F. Hyperoxygenate the client.
- G. Check for secretion clearance.
Correct Answer: A,F,D,C,E,B
Rationale: Check for secretion clearance.
A nurse is assisting with the plan of care for a client who does not speak the same language as the nurse. Which of the following interventions should the nurse include in the plan?
- A. Ensure that a family member is present who can interpret health care information.
- B. Use pictures to reinforce instructions given to the client.
- C. Speak in a loud voice when talking to the client.
- D. Encourage the client to nod to indicate understanding.
Correct Answer: B
Rationale: Using pictures as reinforcement supports effective communication and understanding.