Nokea
A patient is taking Streptomycin. Which finding below requires the nurse to notify the physician?
- A. Patient reports a change in vision.
- B. Patient reports a metallic taste in the mouth.
- C. The patient has ringing in their ears.
- D. The patient has a persistent dry cough.
Correct Answer: C
Rationale: This medication can be very toxic to the ears (cranial nerve 8). Therefore, it is alarming if the patient reports ringing in their ears, which could represent ototoxicity.
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An adult is to have a tracheostomy performed. What is the nursing priority?
- A. Shave the neck
- B. Establish a means of communication
- C. Insert a Foley catheter
- D. Start an IV
Correct Answer: B
Rationale: Establishing a means of communication is the priority, as the client will lose the ability to speak post-tracheostomy.
During the preoperative period, which nursing action will be of greatest priority for a person who is to have a laryngectomy?
- A. Establish a means of communication.
- B. Prepare the bowel by administering enemas until clear.
- C. Teach the client to use an artificial larynx.
- D. Demonstrate the technique for suctioning a laryngectomy tube.
Correct Answer: A
Rationale: Establishing a means of communication is the highest priority preoperatively, as the client will lose the ability to speak post-laryngectomy.
An adult man has a tracheostomy tube in place. Which of the following actions is most appropriate for the nurse to take when suctioning the tracheostomy?
- A. Use a sterile tube each time and suction for 30 seconds
- B. Use sterile technique and turn the suction off as the catheter is introduced
- C. Use clean technique and suction for 10 seconds
- D. Discard the catheter at the end of every shift
Correct Answer: B
Rationale: Suctioning should use sterile technique, with suction off during insertion and applied intermittently for no more than 10 seconds to prevent hypoxia and trauma.
A patient's D-dimer result is <500 ng/mL (FEU). The nurse knows that the D-dimer assesses and this result means?
- A. fibrin degradation fragment; positive for a blood clot
- B. platelet degradation protein; negative for a blood clot
- C. clotting factors; positive for a blood clot
- D. fibrin degradation fragment; negative for a blood clot
Correct Answer: D
Rationale: A d-dimer test assess fibrin degradation fragment. This test doesn't tell us where the clot may be (so it not specific) so it will need to be further investigated by the MD and a positive result doesn't necessarily mean the patient has a clot because some disease processes can cause a false positive. Also, a normal d-dimer is <500 ng/mL (FEU). However, it depends on how the lab reports the assay cut-off value for the d-dimer. Some labs have a cutoff <250 ng/mL (D-DU). However, <500 ng/mL (FEU) is equivalent to <250 ng/mL (D-DU).
While withdrawing the suction catheter from a client's tracheostomy tube, which nursing technique is correct?
- A. Remove the catheter slowly.
- B. Push and pull the catheter.
- C. Plunge the catheter up and down.
- D. Twist and rotate the catheter.
Correct Answer: A
Rationale: Removing the catheter slowly while applying intermittent suction ensures effective secretion removal without causing trauma.