Nokea
A nurse is performing the routine daily cleaning of a tracheostomy. During the procedure, the client coughs and displaces the tracheostomy tube. This negative outcome could have been avoided by
- A. placing an obturator at the client's bedside
- B. having another nurse assist with the procedure
- C. fastening clean tracheostomy ties before removing old ties
- D. placing the client in a flat, supine position
Correct Answer: C
Rationale: fastening clean tracheostomy ties before removing old ties. Fastening clean tracheostomy ties before removing old ones will ensure that the tracheostomy is secured during the entire cleaning procedure. The obturator is useful to keep the airway open only after the tracheostomy outer tube is coughed out. A second nurse is not needed. Changing the position may not prevent a dislodged tracheostomy.
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The nurse is caring for a client with a history of chronic kidney disease who is receiving hemodialysis. Which of the following findings should the nurse report immediately?
- A. Blood pressure of 130/80 mmHg
- B. Weight gain of 1 kg since last dialysis
- C. Fistula site with a strong thrill
- D. Temperature of 100.8°F (38.2°C)
Correct Answer: D
Rationale: A temperature of 100.8°F suggests infection, a serious complication in hemodialysis patients due to their immunocompromised state and vascular access. Options A, B, and C are normal: BP is stable, 1 kg weight gain is expected fluid retention, and a strong thrill indicates a patent fistula.
The nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who is receiving ipratropium (Atrovent) via inhaler. Which of the following client statements would be of GREATest concern to the nurse?
- A. I use my inhaler four times a day.
- B. I have a dry mouth.
- C. I feel dizzy sometimes.
- D. I rinse my mouth after using the inhaler.
Correct Answer: C
Rationale: Dizziness may indicate systemic absorption or hypoxia, a serious concern in COPD requiring evaluation. Options A, B, and D are less concerning: four times daily is standard, dry mouth is a common side effect, and rinsing is appropriate.
During the rehabilitative phase, the client's burns become infected with pseudomonas. The topical dressing most likely to be ordered for the client is:
- A. Silver sulfadiazine (Silvadene)
- B. Poviodine (Betadine)
- C. Mafenide acetate (Sulfamylon)
- D. Silver nitrate
Correct Answer: C
Rationale: Mafenide acetate (Sulfamylon) is particularly effective against Pseudomonas infections due to its broad-spectrum antibacterial activity and ability to penetrate eschar. Silver sulfadiazine is less effective against Pseudomonas, and povidone-iodine and silver nitrate are not the primary choices for Pseudomonas infections. Answers A, B, and D are incorrect because they are less effective for this specific infection.
A client is admitted to the emergency room in severe emotional distress. The client's respirations are 42/min, and the blood gases reveal a pH of 7.5 and a PaCO2 of 34.
Initially the nurse should
- A. instruct the client to breathe into a paper bag.
- B. start an IV of D5W.
- C. administer O2.
- D. have the client place his head between his knees.
Correct Answer: A
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-because of hyperventilation, client is in alkalosis; having him rebreathe his own carbon dioxide will reverse his blood gas imbalance (2) does not address the problem (3) is not hypoxic (4) is done when a client feels faint
The nurse is providing instructions for a client with pneumonia. What is the most important information to convey to the client?
- A. Take at least 2 weeks off from work.
- B. You will need another chest x-ray in 6 weeks.
- C. Take a longer temperature range of time.
- D. Complete all of the antibiotic even if your findings decrease.
Correct Answer: D
Rationale: Complete all of the antibiotic even if your findings decrease. Finishing the full antibiotic course prevents recurrence and resistance.