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A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps?
- A. Scrub the inside and outside of the inner cannula with a small brush.
- B. Wipe the inside of the inner cannula with a folded pipe cleaner.
- C. Cleanse the stoma site with 0.9% sodium chloride solution.
- D. Unlock and remove the inner cannula.
- E. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin.
Correct Answer: E,D,A,B,C
Rationale: E: Prepare solution. D: Remove cannula. A: Scrub cannula. B: Wipe cannula. C: Cleanse stoma maintains sterility.
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A nurse is preparing to perform a fecal occult blood test of stool specimens for a client. Which of the following actions should the nurse plan to take?
- A. Repeat the test three times using the same stool specimen.
- B. Wear sterile gloves when handling the stool specimen.
- C. Have the client defecate into a bedpan that contains a small amount of water.
- D. Ensure that the stool specimen does not contain urine.
Correct Answer: D
Rationale: Ensuring no urine contamination maintains specimen integrity for accurate testing.
The client is at risk for developing ___ as evidenced by the client's ___
- A. Infection
- B. WBC count
Correct Answer: A,B
Rationale: A: Chemotherapy lowers immunity, increasing infection risk. B: Decreased WBC count (4,000/mm³) indicates leukopenia.
A nurse is reinforcing teaching with a client who has crutches regarding the use of the three-point gait. Which of the following instructions should the nurse include?
- A. Bear weight on the unaffected leg.
- B. Stand with the crutch tips against the feet.
- C. Hold the arms straight when walking.
- D. Keep the crutches at the level of the axillae.
Correct Answer: A
Rationale: In the three-point gait, weight is borne on the unaffected leg while moving crutches and the affected leg together.
A nurse is contributing to a community center's in-service program about early detection of breast cancer. Which of the following recommendations should the nurse make for female clients who do not have a family history of breast cancer?
- A. You should start receiving mammograms as early as age 40.
- B. You should receive a breast ultrasound every 3 years after age 50.
- C. You should start performing monthly breast self-examinations at age 35.
- D. You should receive a breast examination from your provider each year after age 30.
Correct Answer: A
Rationale: Mammograms starting at age 40 are recommended for average-risk women.
A nurse is collecting data from a client who is immobile and has a potential deep-vein thrombosis. Which of the following findings should the nurse report to the provider?
- A. Calf swelling
- B. Bradycardia
- C. Clammy skin
- D. Tortuous veins
Correct Answer: A
Rationale: Calf swelling is a common sign of deep-vein thrombosis (DVT) and requires immediate reporting due to risk of complications.