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A young adult is hospitalized with a seizure disorder. The client, who is in a bed with padded side rails, has a tonic-clonic seizure. In what order should the nurse take the following actions?
- A. Loosen clothing around the client's neck.
- B. Turn the client on his or her side.
- C. Clear the area around the client.
- D. Suction the airway.
Correct Answer: C,B,A,D
Rationale: First, clear the area to prevent injury, turn the client on their side to maintain airway patency, loosen clothing to ease breathing, and suction if needed to clear secretions.
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The nurse is preparing a teaching plan for a 45-year-old client recently diagnosed with type 2 diabetes mellitus. What is the first step in this process?
- A. Establish goals.
- B. Assess the client's learning needs.
- C. Set priorities of learning needs.
- D. Select teaching strategies.
Correct Answer: B
Rationale: Assessing the client's learning needs is the first step to tailor education to their knowledge level, preferences, and barriers, ensuring effective teaching.
A client with a history of type 2 diabetes is prescribed metformin (Glucophage). The nurse should instruct the client to:
- A. Take the medication with meals.
- B. Avoid alcohol consumption.
- C. Take the medication at bedtime.
- D. Stop the medication if nausea occurs.
Correct Answer: A, B
Rationale: Metformin should be taken with meals to reduce gastrointestinal upset, and alcohol should be avoided to prevent lactic acidosis.
The nurse is reviewing the serum laboratory test results for a client with a diagnosis of sickle cell anemia. Which parameter should the nurse anticipate will be elevated?
- A. Sodium
- B. Hemoglobin-S
- C. Hemoglobin A1c
- D. Prothrombin time
Correct Answer: B
Rationale: Sickle cell anemia is a severe anemia that affects African Americans predominantly and is characterized by sickled hemoglobin, or HgbS. The client must have two abnormal genes yielding hemoglobin-S to have sickle cell anemia. A client could have sickle cell trait by carrying one hemoglobin-A gene and one hemoglobin-S gene; then, the client has a less severe form of sickle cell anemia. The remaining options are unrelated to sickle cell anemia.
The nurse is preparing to suction an adult client with a tracheostomy who has copious amounts of secretions. Which action should the nurse take to accomplish this procedure safely and effectively?
- A. Hyperoxygenate the client after the procedure only.
- B. Apply continuous suction in the airway for up to 20 seconds.
- C. Set the wall suction pressure range between 80 and 120 mm Hg.
- D. Occlude the Y-port of the catheter while advancing it into the tracheostomy.
Correct Answer: C
Rationale: The safe wall suction range for an adult is 80 to 120 mm Hg, making option 3 the action that is consistent with safe and effective practice. The nurse should hyperoxygenate the client both before and after suctioning. The nurse should use intermittent suction in the airway (not constant) for up to 10 to 15 seconds. The nurse should advance the catheter into the tracheostomy without occluding the Y-port to minimize mucosal trauma and aspiration of the client's oxygen.
To improve the accuracy of client identification, the nurse must use at least two identifiers when providing care, treatment, or services. Which of the following are appropriate? Select all that apply.
- A. Room number.
- B. Bed number.
- C. Medical record number.
- D. Name band.
- E. Social security number.
Correct Answer: C,D,E
Rationale: Appropriate identifiers include medical record number, name band, and social security number, as they are unique to the client. Room and bed numbers are not reliable identifiers.