Nokea
A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student demonstrates that more teaching is needed?
- A. Applying suction while withdrawing the catheter
- B. Preoxygenating the client before suctioning
- C. Suctioning up to three times if necessary
- D. Suctioning for a duration of 10 to 15 seconds each time
Correct Answer: A
Rationale: The correct answer is A. When suctioning a tracheostomy, the student should not apply suction while withdrawing the catheter to prevent mucosal damage. The correct technique involves inserting the catheter without applying suction, then withdrawing it while applying suction. This helps to clear secretions effectively without causing trauma. Choices B, C, and D are incorrect. Preoxygenating the client is a recommended practice to prevent hypoxemia during suctioning. Suctioning up to three times if necessary and suctioning for 10-15 seconds each time are appropriate techniques to clear secretions effectively without causing harm.
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The nurse is caring for a client 2 hours after a right lower lobectomy. During the evaluation of the water-seal chest drainage system, it is noted that the fluid level bubbles constantly in the water seal chamber. On inspection of the chest dressing and tubing, the nurse does not find any air leaks in the system. The next best action for the nurse is to:
- A. Check for subcutaneous emphysema in the upper torso.
- B. Reposition the client to a position of comfort.
- C. Call the health care provider as soon as possible.
- D. Check for any increase in the amount of thoracic drainage.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A patient comes to the clinic with a complaint of a dull pain in the anterior and posterior neck. On examination, the nurse notes that the patient has full range of motion (ROM) of the neck and no throat redness or enlarged head or neck lymph nodes. What will be the nurse’s next appropriate assessment indicated by these findings?
- A. Palpation of the liver
- B. Auscultation of bowel sounds
- C. Inspection of the patient’s ears
- D. Palpation for the presence of left flank pain
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A cheerful, elderly widow comes to the community clinic for her annual check-up. She is in reasonably good health, but she has a hearing loss of 40 dB. She confides, 'I don't get out much. I used to be really active, but the older I get, the more trouble I have hearing. It can be really embarrassing.' What is the priority nursing diagnosis?
- A. Social Interaction, Impaired related to perceived inability to interact
- B. Disturbed Sensory Perception related to progressive hearing loss
- C. Knowledge Deficit related to pathophysiological processes
- D. Coping, Ineffective related to change in sensory abilities
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client takes atorvastatin (Lipitor), with laboratory results showing a blood urea nitrogen (BUN) of 33 mg/dL and creatinine of 2.8 mg/dL. What action by the nurse is best?
- A. Ask if the client eats grapefruit.
- B. Assess the client for dehydration.
- C. Facilitate admission to the hospital.
- D. Obtain a random urinalysis.
Correct Answer: A
Rationale: The correct answer is A: Ask if the client eats grapefruit. Atorvastatin can interact with grapefruit juice, leading to increased drug levels and potential toxicity. The elevated BUN and creatinine levels suggest possible kidney impairment, which could be exacerbated by the drug interaction. Assessing for grapefruit consumption allows the nurse to address this potential risk factor.
B: Assessing for dehydration would not directly address the potential drug interaction with grapefruit.
C: Hospital admission is not necessary based solely on the information provided; this would be an extreme action without further assessment.
D: Obtaining a random urinalysis would not provide relevant information related to the potential drug interaction with grapefruit.
What educational information related to nutrition would you provide to a client with anxiety?
- A. High blood pressure
- B. Increased heart rate
- C. Decreased oxygen supply
- D. Muscle relaxation
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.