Nokea
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.
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The client admitted for recurrent aspiration pneumonia is at risk for bronchiectasis. Which intervention should the nurse anticipate the health-care provider to order?
- A. Administer intravenous antibiotics for seven (7) days.
- B. Insert a subclavian line and initiate total parenteral nutrition.
- C. Provide a low-calorie and low-sodium restricted diet.
- D. Encourage the client to turn, cough, and deep breathe frequently.
Correct Answer: D
Rationale: Recurrent aspiration pneumonia predisposes to bronchiectasis due to chronic airway damage. Turning, coughing, and deep breathing (D) prevent secretion stasis and further infections. Antibiotics (A) treat active infection, not prevention. TPN (B) is for malnutrition, not directly related. Dietary restrictions (C) are irrelevant.
The client is four (4) hours post-lobectomy for cancer of the lung. Which assessment data warrant immediate intervention by the nurse?
- A. The client has an intake of 1,500 mL IV and an output of 1,000 mL.
- B. The client has 450 mL of bright-red drainage in the chest tube.
- C. The client is complaining of pain at a '10' on a 1-to-10 scale.
- D. The client has absent lung sounds on the side of the surgery.
Correct Answer: B
Rationale: 450 mL bright-red drainage (B) suggests hemorrhage, requiring immediate action. Fluid balance (A), severe pain (C), and absent lung sounds (D) are expected or less urgent.
An adult had a negative purified protein derivative (PPD) test when he was first employed two years ago. A year later, the client had a positive PPD test and a negative chest x-ray. This indicated that at that time the client:
- A. was less susceptible to a tuberculosis infection than the year before.
- B. had acquired some degree of passive immunity to tuberculosis.
- C. had fought the Mycobacterium tuberculosis but had not developed active tuberculosis.
- D. had a mild tuberculosis infection in an organ other than the lung.
Correct Answer: C
Rationale: A positive PPD with a negative chest x-ray indicates exposure to Mycobacterium tuberculosis with an immune response but no active pulmonary disease.
Where on the client should the nurse position the sensor of the pulse oximeter to obtain an accurate measurement?
- A. Apply it to the client's finger.
- B. Apply it to the client's palm.
- C. Clip it to the client's earlobe.
- D. Wrap it around the client's leg.
Correct Answer: A
Rationale: The finger is the most common and reliable site for pulse oximetry, providing accurate oxygenation readings.
The nurse is assessing the client with COPD. Which health promotion information is most important for the nurse to obtain?
- A. Number of years the client has smoked.
- B. Risk factors for complications.
- C. Ability to administer inhaled medication.
- D. Willingness to modify lifestyle.
Correct Answer: C
Rationale: Correct inhaler use (C) ensures effective COPD management, a priority for health promotion. Smoking history (A), risk factors (B), and lifestyle (D) are important but secondary.