Nokea
A nurse is demonstrating suctioning a tracheostomy during the annual skills review. What action by the student demonstrates that more teaching is needed?
- A. Applying suction while inserting the catheter
- B. Preoxygenating the client prior to suctioning
- C. Suctioning for a total of three times if needed
- D. Suctioning for only 10 to 15 seconds each time
Correct Answer: A
Rationale: The correct answer is A because applying suction while inserting the catheter can cause damage to the tracheal mucosa and lead to bleeding or injury. The correct technique is to insert the catheter without applying suction, then apply suction while withdrawing it. Preoxygenating the client (B) is a recommended practice to prevent hypoxia. Suctioning for a total of three times if needed (C) and suctioning for only 10 to 15 seconds each time (D) are both appropriate and safe suctioning practices.
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When examining the posterior pharynx and tonsils, which of the following objective data does the nurse note?
- A. Difficulty in sneezing
- B. Suppressed gag reflex
- C. Deformities
- D. Inflammation
Correct Answer: D
Rationale: The correct answer is D. Inflammation is a key finding during examination of the posterior pharynx and tonsils, especially in infections such as tonsillitis. A (difficulty in sneezing) is unrelated to pharyngeal assessment. B (suppressed gag reflex) might indicate neurological issues but isn't typically noted during routine exams. C (deformities) is rare unless there's structural abnormality.
A client has experienced pulmonary embolism. A nurse assesses for which symptom, which is most commonly reported?
- A. Hot, flushed feeling.
- B. Sudden chills and fever.
- C. Chest pain that occurs suddenly.
- D. Nausea and vomiting.
Correct Answer: C
Rationale: The correct answer is C: Chest pain that occurs suddenly. Pulmonary embolism typically presents with sudden chest pain due to a blockage in the pulmonary arteries. This is a result of a blood clot traveling to the lungs, causing a sharp and stabbing pain. The other options are not typically associated with pulmonary embolism. A hot, flushed feeling (A) is more indicative of a fever or infection, sudden chills and fever (B) may occur in sepsis or the flu, and nausea and vomiting (D) are more commonly seen in gastrointestinal issues.
Which respiratory division includes the larynx and respiratory structures distal?
- A. upper respiratory tract.
- B. lower respiratory tract.
- C. internal respiratory tract.
- D. alveoli of the respiratory tract.
Correct Answer: B
Rationale: The correct answer is B, lower respiratory tract. The larynx and structures distal to it, such as the trachea, bronchi, and lungs, are part of the lower respiratory tract. The upper respiratory tract (choice A) includes the nose, nasal cavity, pharynx, and larynx. Internal respiratory tract (choice C) is not a commonly used term in respiratory anatomy. Alveoli of the respiratory tract (choice D) specifically refer to the air sacs in the lungs where gas exchange occurs, not the entire respiratory division that includes the larynx and structures distal to it.
Which diagnostic test is commonly used to assess heart function in heart failure?
- A. Electrocardiogram (ECG or EKG)
- B. Magnetic Resonance Imaging (MRI)
- C. Colonoscopy
- D. Blood glucose test
Correct Answer: A
Rationale: The correct answer is A: Electrocardiogram (ECG or EKG). An ECG is commonly used to assess heart function in heart failure because it provides information on the heart's electrical activity, rhythm, and any abnormalities. It can detect conditions such as arrhythmias, ischemia, and previous heart attacks. Other choices are incorrect: B (MRI) is more for imaging the structure of the heart, C (Colonoscopy) is for examining the colon, and D (Blood glucose test) is for measuring blood sugar levels, not heart function.
A nurse working in a geriatric clinic sees clients with "cold" symptoms and rhinitis. The primary health care provider (PHCP) often leaves a prescription for diphenhydramine. What action by the nurse is best?
- A. Teach the client about possible drowsiness.
- B. Instruct the client to drink plenty of water.
- C. Consult with the PHCP about the medication.
- D. Encourage the client to take the medication with food.
Correct Answer: C
Rationale: The correct answer is C: Consult with the PHCP about the medication. This is the best action because diphenhydramine may not be the most appropriate medication for older adults due to potential side effects like increased risk of falls, confusion, and urinary retention. Consulting with the PHCP will ensure that the medication is safe and effective for the client.
A: Teaching about drowsiness is important but not the priority.
B: Drinking water is generally good advice but not specific to diphenhydramine.
D: Taking medication with food can help reduce stomach upset but doesn't address the concerns related to diphenhydramine in older adults.