Nokea
A nurse is performing nasopharyngeal suctioning for an adult client. Which of the following techniques should the nurse use?
- A. Apply suction while inserting the catheter
- B. Apply intermittent suction for 30 seconds
- C. Insert the catheter 10 cm (4 in)
- D. Wait 1 min between suctioning attempts
Correct Answer: D
Rationale: Waiting 1 minute between attempts allows oxygenation and prevents hypoxia.
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The client becomes combative and threatens other clients and staff.
A nurse is working with a client who becomes combative and threatens other clients and staff. Which of the following actions should the nurse take?
- A. Stand in front of the client to block them from others in the room.
- B. Apply restraints according to the facility's standing order.
- C. Ensure there are enough staff members available for assistance.
- D. Obtain a PRN prescription for restraints from the provider.
Correct Answer: C
Rationale: Ensuring staff availability ensures safety without immediate restraint use.
The client has mild hypertension.
A nurse is reinforcing teaching about healthy lifestyle changes with a female client who has mild hypertension. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should exercise for 15 minutes two times per week.
- B. I should decrease my salt intake to 2 grams per day.
- C. I will set my blood pressure goal at 130 over 84.
- D. I can have two glasses of wine with dinner.
Correct Answer: B
Rationale: Reducing salt to 2 grams daily helps manage hypertension, showing understanding.
A home health nurse is conducting a home inspection for a client who is at risk for falls. Which of the following instructions should the nurse provide for the client?
- A. Place the bedside table 2 feet away from the bed.
- B. Keep lighting in the home dim.
- C. Place area rugs on slick floor surfaces.
- D. Move the client's bed to the main floor of the house.
Correct Answer: D
Rationale: Moving the bed to the main floor reduces stair-related fall risks.
A nurse is caring for a client who has dementia. Which of the following findings should the nurse expect?
- A. Memory loss that disrupts ADLs
- B. Acute onset of confusion
- C. Illusions
- D. Catatonia
Correct Answer: A
Rationale: Memory loss disrupting ADLs is a hallmark of dementia.
The client is 12 hr postpartum and has deep-vein thrombosis of the left leg. The client is receiving anticoagulant therapy.
A nurse is caring for a client who is 12 hr postpartum and has deep-vein thrombosis of the left leg. The client is receiving anticoagulant therapy. Which of the following actions should the nurse take?
- A. Massage the affected extremity every 4 hr.
- B. Initiate bed rest.
- C. Apply an ice pack to the affected extremity for 20 min every 2 hr.
- D. Administer aspirin for pain.
Correct Answer: B
Rationale: Bed rest prevents dislodging the clot while on anticoagulants.