Nokea
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? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
- A. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin.
- B. Unlock and remove the inner cannula.
- C. Scrub the inside and outside of the inner cannula with a small brush.
- D. Cleanse the stoma site with 0.9% sodium chloride solution.
- E. Wipe the inside of the inner cannula with a folded pipe cleaner.
Correct Answer: A,B,C,E,D
Rationale: A: Prepare solution. B: Remove cannula. C: Scrub cannula. E: Wipe cannula. D: Cleanse stoma ensures sterile technique.
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A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? (Select all that apply.)
- A. A client reports being dissatisfied with the temperature of the meals provided.
- B. A client receives burns from a heating pad.
- C. A client becomes disoriented and falls out of bed.
- D. A client is unable to afford the physical therapy that the provider recommends.
- E. A client's visitor becomes dizzy and faints in the client's room.
Correct Answer: B,C,E
Rationale: B: Burns indicate harm. C: Falls require reporting. E: Visitor fainting is an unexpected event.
A nurse is caring for a client who is postoperative following a laminectomy. Which of the following actions should the nurse take when repositioning the client?
- A. Place a pillow between the client's legs prior to logrolling.
- B. Place the client in semi-Fowler's position prior to logrolling.
- C. Place the client's arms above her head prior to logrolling.
- D. Place the bed in the lowest position before logrolling the client.
Correct Answer: A
Rationale: A pillow between legs maintains spinal alignment during logrolling post-laminectomy.
Vital Signs
0115:
Tympanic temperature 37.4° C (99.4° F)
Heart rate 95/min
Blood pressure 136/89 mm Hg
Respiratory rate 22/min
Oxygen saturation 95% on room air
1930:
Tympanic temperature 36.9° C (98.4° F)
Heart rate 118/min
Blood pressure 156/94 mm Hg
Respiratory rate 20/min
Oxygen saturation 97% on room air
A nurse is reviewing the medical record of a client. Click to highlight below the findings that require immediate follow-up.
- A. Neurological- Alert and oriented to person, place, and time; deep tendon reflexes 4+
- B. Musculoskeletal - Generalized weakness with equal bilateral muscle strength and mild leg cramping
- C. Respiratory- Lungs clear
- D. Cardiovascular- Heart rate irregular: Heart rate 95/min
- E. Gastrointestinal- Bowel sounds hyperactive x 4 quadrants
Correct Answer: D, E
Rationale: D: Irregular heart rate may indicate arrhythmia. E: Hyperactive bowel sounds suggest a gastrointestinal issue.
A nurse is caring for a client who has insomnia. Which of the following actions should the nurse take?
- A. Administer prescribed diuretics in the evening.
- B. Use overhead lighting when checking equipment.
- C. Keep the door to the client's room closed.
- D. Provide the client with snug-fitting nightwear.
Correct Answer: C
Rationale: A closed door reduces noise, promoting sleep.
A nurse is assisting with scoliosis screenings for students at a public school. Which of the following findings should the nurse recognize as an indication of scoliosis?
- A. Unequal height of the shoulders
- B. Expansion of the upper intercostal spaces
- C. Increased convex curve of the cervical spine
- D. Increased concave curve of the thoracic spine
Correct Answer: A
Rationale: Unequal shoulder height is a classic sign of scoliosis due to spinal curvature.