Nokea
A nurse is preparing to perform tracheostomy care for a client. In which order should the nurse take the following steps?
- A. Ensure a method to communicate during the procedure.
- B. Wear clean gloves to remove the tracheostomy dressing.
- C. Clean the inner cannula using a small brush.
- D. Explain the procedure to the client.
- E. Apply clean tracheostomy ties.
Correct Answer: D,A,B,C,E
Rationale: The sequence is: Explain the procedure (D) to inform the client, ensure communication (A) during the process, remove the dressing with gloves (B), clean the cannula (C), and apply new ties (E). This order ensures safety and client comfort.
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A nurse is collecting data from a client who has a subdural hematoma following a motor-vehicle crash. For which of the following findings should the nurse identify that the client is experiencing an increase in intracranial pressure?
- A. The client has a delayed response to verbal commands.
- B. The client has ecchymosis around the eyes.
- C. The client is unable to remember details of the motor-vehicle crash.
- D. The client reports ringing in the ears.
Correct Answer: A
Rationale: Delayed verbal response indicates rising intracranial pressure (ICP) affecting brain function. Ecchymosis and amnesia are hematoma signs, and ringing ears isn't specific to ICP.
A nurse is assisting with the plan of care for a client who has osteoarthritis. The client reports knee stiffness upon ambulation. Which of the following interventions should the nurse include in the plan of care?
- A. Apply moist heat prior to ambulation.
- B. Delay ambulation until the next day
- C. Use a continuous passive motion machine
- D. Rest in a soft chair
- E. Apply cold packs.
- F. Increase weight-bearing exercise.
- G. Avoid all movement.
Correct Answer: A
Rationale: Moist heat reduces stiffness and improves mobility in osteoarthritis.
A nurse is assisting in the plan of care for a client who has constipation after receiving opioid medication for incisional pain. Which of the following actions should the nurse take first?
- A. Encourage the client to increase oral intake of fluids.
- B. Auscultate the client's abdomen for bowel sounds.
- C. Provide the client privacy with a set time to defecate.
- D. Administer a fiber-based laxative to the client.
- E. Increase physical activity.
- F. Check medication history.
- G. Apply heat to the abdomen.
Correct Answer: B
Rationale: Auscultating bowel sounds assesses the underlying issue (e.g., ileus) before interventions like fluids or laxatives.
A nurse is preparing to administer subcutaneous enoxaparin. In which order should the nurse perform the following steps?
- A. Locate the injection site 5 cm (2 in) to the right or left of the umbilicus.
- B. Check the medication administration record to verify the client's allergies.
- C. Slowly inject the medication into the site without aspirating.
- D. Pinch clean skin at the injection site and dart the needle into the skinfold at a 90° angle.
- E. Ensure an air bubble is present in the prefilled enoxaparin syringe.
Correct Answer: B,E,A,D,C
Rationale: The sequence is: Verify allergies (B), check the air bubble (E), locate the site (A), pinch and inject at 90° (D), and inject slowly without aspirating (C) per enoxaparin protocol.
Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4
Medical History
Today, 0700:
Admitting Diagnosis: Heart Failure
Past medical history of heart failure, coronary artery disease, sleep apnea
Client reports diarrhea, dry mouth, and unusual thirst for the past three days
A nurse is assisting in the care of a male client who has a new prescription for furosemide. Which of the following client findings should the nurse identify as a contraindication to the administration of furosemide?
- A. Potassium level
- B. Blood pressure
- C. Prescription for digoxin
- D. Client verbal report
- E. BUN
Correct Answer: A
Rationale: Furosemide, a loop diuretic, treats heart failure but depletes potassium, risking hypokalemia. A low potassium level (e.g., <3.5 mEq/L) contraindicates its use hypokalemia causes arrhythmias, especially with heart failure's cardiac strain, per pharmacology standards. Blood pressure matters hypotension may worsen with diuresis but isn't a direct contraindication unless extreme. Digoxin use heightens hypokalemia risk (enhancing toxicity), but potassium level drives the decision. The client's report of diarrhea and thirst suggests dehydration, a caution, not a strict contraindication. Low potassium demands correction (e.g., supplements) before furosemide, preventing lethal complications like ventricular fibrillation, making it the critical finding to identify.