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?
- 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. Wipe the inside of the inner cannula with a folded pipe cleaner.
- E. Cleanse the stoma site with 0.9% sodium chloride solution.
Correct Answer: A,B,C,D,E
Rationale: A,B,C,D,E sequence prepares solution, removes cannula, cleans it, and then cleans stoma, maintaining sterility.
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A nurse in a provider's office is reviewing data from a client's medical record. Which of the following findings should the nurse identify as a risk factor for cardiovascular disease?
- A. BMI of 24
- B. Type 1 diabetes mellitus
- C. Family history of osteoporosis
- D. Orthostatic hypotension
Correct Answer: B
Rationale: Type 1 diabetes increases cardiovascular risk due to vascular complications.
0800:
The client is alert and oriented to person, place, and time. Seizure pads placed on the client's bed. Suction equipment is at the client's bedside and functioning. Oxygen equipment is at the client's bedside.
1000:
Client is in bed and reports experiencing an aura, followed by generalized jerking contractions of arms and legs. Client incontinent of urine and unresponsive to commands.
1004:
Client's jerking contractions of arms and legs stopped. Client is confused and lethargic. Bilateral breath sounds clear. Oxygen applied 3 L/min via nasal cannula. Oxygen saturation 95%.
At 1000 the nurse enters the client's room. The first action the nurse should take is followed by
- A. Remove the pillows
- B. Turn the client to their side
- C. call for emergency assistance
- E. initiate IV fluids
- F. document seizure
- G. prepare medications
Correct Answer: A,B
Rationale: Removing pillows prevents airway obstruction; turning to the side aids drainage during a seizure.
A nurse is observing an assistive personnel (AP) provide postmortem care for a client prior to visitation by their loved ones. Which of the following actions by the AP requires intervention by the nurse?
- A. Removing the client's dentures from their mouth
- B. Washing the client's face
- C. Closing the client's eyes
- D. Gathering the client's personal belongings
Correct Answer: A
Rationale: Removing dentures is a nursing task to ensure proper handling, requiring intervention.
Nurses' Notes Day 1:
Collecting client data on food safety.
Raw meats and raw vegetables are prepared together on one cutting board. Refrigerator is set to 6.7° C (44° F)
Leftovers are discarded after 7 days in refrigerator. Frozen foods are defrosted on the countertop.
Client washes hands for 10 seconds before cooking.
Leftovers are refrigerated after sitting on the countertop for 3 hr.
Reinforced client teaching about food safety. Follow-up visit scheduled in 2 weeks.
Day 14:
At client's home to collect follow-up data on food safety. Uses one cutting board to prepare raw meats and a different cutting board to prepare raw vegetables.
The refrigerator is set to 5.6° C (42° F).
Leftovers are discarded after 2 days in refrigerator. Frozen foods are defrosted in the refrigerator.
Client washes hands for 15 seconds before cooking.
A home health nurse is assisting in the care of a client. Select the 4 findings that indicate an understanding of the reinforced teaching.
- A. Use of cutting board
- B. Amount of time washing hands
- C. Time leftovers sit unrefrigerated on countertop
- D. Refrigerator temperature
- E. Defrosting of frozen foods
- F. Leftover storage time in refrigerator
Correct Answer: A,B,E,F
Rationale:
A nurse is reinforcing teaching with a client about the use of a quad cane. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should wear shoes with smooth soles to help slide my weak leg forward.
- B. I will move the cane forward 18 inches.
- C. I will hold the cane on my stronger side.
- D. I should move my stronger leg forward before moving my weaker leg.
Correct Answer: C
Rationale: Holding the cane on the stronger side enhances stability and support for the weaker side.