Nokea
A nurse is preparing to remove an NG tube for a client. Which of the following actions should the nurse take first?
- A. Disconnect the tube from the wall suction.
- B. Perform hand hygiene and don gloves.
- C. Observe the amount and color of drainage.
- D. Verify provider order to discontinue the tube.
Correct Answer: D
Rationale: The correct answer is D: Verify provider order to discontinue the tube. This is the first step the nurse should take before removing the NG tube to ensure that the removal is in line with the provider's instructions. Removing the tube without a valid order can lead to complications. Disconnecting the tube from wall suction (A) should be done after verifying the order. Performing hand hygiene and donning gloves (B) is important but can be done after verifying the order. Observing the amount and color of drainage (C) is important but should come after verifying the order.
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A nurse is instructing a client about postural drainage. The nurse should have the client lie on his stomach with his head lower than his feet to mobilize secretions from which of the following lung segments?
- A. Apical segments
- B. Both upper lobes
- C. Anterior segments of both lower lobes
- D. Posterior segments of both lower lobes
Correct Answer: D
Rationale: Prone Trendelenburg position aids in secretion clearance from posterior lung segments.
A nurse is preparing to suction the airway of a client who has a tracheostomy. Identify the sequence of actions the nurse should take after performing hand hygiene.
- A. Adjust the suction to 120 to 150 mm Hg.
- B. Apply intermittent suction while rotating the catheter.
- C. Don sterile gloves.
- D. Check the function of the suction catheter.
- E. Insert the catheter without suction.
- F. Hyperoxygenate the client.
- G. Check for secretion clearance.
Correct Answer: A,F,D,C,E,B
Rationale: Check for secretion clearance.
A nurse is caring for a client receiving IV therapy in the left forearm and notices that the site is red, swollen, and warm. Which of the following actions should the nurse perform first?
- A. Insert an IV catheter in the opposite extremity.
- B. Discontinue the existing IV infusion.
- C. Apply warm, moist compresses to the site.
- D. Elevate the extremity.
Correct Answer: B
Rationale: The correct action is to discontinue the existing IV infusion (Choice B) first. The redness, swelling, and warmth at the IV site indicate phlebitis, which is inflammation of the vein. Discontinuing the infusion is crucial to prevent further damage and infection. This step helps to stop the irritant (IV solution) from causing more harm. Inserting an IV catheter in the opposite extremity (Choice A) does not address the current issue and may lead to the same problem. Applying warm, moist compresses (Choice C) could potentially worsen the inflammation. Elevating the extremity (Choice D) may provide some relief, but it does not address the root cause. Therefore, discontinuing the existing IV infusion is the most appropriate immediate action to take in this situation.
A nurse is collecting data about a client's cranial nerves. Which of the following methods should the nurse use to identify a problem with cranial nerve II?
- A. Use a Snellen chart.
- B. Determine if the client's speech is hoarse.
- C. Present the client with mildly scented aromas.
- D. Ask the client to clench teeth.
Correct Answer: A
Rationale: The correct answer is A: Use a Snellen chart. Cranial nerve II, the optic nerve, is responsible for vision. By using a Snellen chart, the nurse can assess the client's visual acuity, which directly relates to the function of cranial nerve II. This method specifically targets the nerve in question and provides objective data on the client's vision.
Incorrect choices:
B: Determining if the client's speech is hoarse would assess cranial nerve X, the vagus nerve, responsible for speech and swallowing.
C: Presenting the client with scented aromas would assess cranial nerve I, the olfactory nerve, responsible for smell.
D: Asking the client to clench teeth would assess cranial nerve V, the trigeminal nerve, responsible for facial sensation and jaw movement.
A nurse is preparing to remove a client's urinary catheter. After performing hand hygiene, which of the following actions should the nurse take?
- A. Position the client supine.
- B. Have the client bear down during removal.
- C. Cleanse the perineal area with an antiseptic.
- D. Deflate the balloon halfway and then pull out the catheter.
Correct Answer: A
Rationale: The correct answer is A: Position the client supine. This position allows for easier access to the urinary catheter and minimizes the risk of spillage or contamination. Supine position also provides better comfort and stability for the client during the catheter removal process.
Summary of other choices:
B: Having the client bear down during removal can increase the risk of injury and discomfort.
C: Cleaning the perineal area with an antiseptic is important but should be done after removing the catheter.
D: Deflating the balloon halfway and pulling out the catheter can cause pain and discomfort for the client and may lead to trauma.