Nokea
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.
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When administering oxygen to the client through a partial rebreathing mask, which observation is most important for the nurse to report to the respiratory therapy department?
- A. Moisture is accumulating inside the mask.
- B. The bag collapses during inspiration.
- C. The mask covers the client's mouth and nose.
- D. The strap around the client's head is snug.
Correct Answer: B
Rationale: A collapsing bag during inspiration indicates inadequate oxygen flow, which must be reported to ensure proper oxygen delivery.
You're educating a patient about Warfarin (Coumadin) and how it is used to treat blood clots. Which statements by the patient require you to re-educate them about how this medication works? Select all that apply:
- A. This medication will help dissolve the blood clot.
- B. This medication will prevent another blood clot from forming.
- C. This medication will help prevent the blood clot from becoming bigger in size.
- D. This medication starts working immediately after the first dose.
Correct Answer: A,D
Rationale: Warfarin (Coumadin) does NOT dissolve blood clots. It prevents blood clots from forming, and if one is present, it will help prevent it from becoming bigger. If the blood clot becomes bigger it may break off and travel in blood circulation. This can lead to a pulmonary embolism, heart attack, or stroke. Warfarin (Coumadin) does NOT start working immediately. It takes about 3-5 days of scheduled doses to start achieving a therapeutic INR level. It is very common that a patient will be on Heparin while taking Warfarin until INR levels are therapeutic.
The nurse is completing the admission assessment on a 13-year-old client diagnosed with an acute exacerbation of asthma. Which signs and symptoms would the nurse expect to find?
- A. Fever and crepitus.
- B. Rales and hives.
- C. Dyspnea and wheezing.
- D. Normal chest shape and eupnea.
Correct Answer: C
Rationale: Asthma exacerbation causes dyspnea and wheezing (C) from bronchoconstriction. Fever/crepitus (A), rales/hives (B), and normal breathing (D) are unrelated or incorrect.
Which priority intervention should the nurse implement for the client diagnosed with coal workers' pneumoconiosis?
- A. Monitor the client's intake and output.
- B. Assess for black-streaked sputum.
- C. Monitor the white blood cell count daily.
- D. Assess the client's activity level every shift.
Correct Answer: B
Rationale: Black-streaked sputum (B) is a hallmark of coal workers' pneumoconiosis due to coal dust deposition, making its assessment a priority to confirm disease impact. Intake/output (A) is non-specific. Daily WBC counts (C) are unnecessary unless infection is suspected. Activity level (D) is secondary to symptom assessment.
The charge nurse is making client assignments on a medical floor. Which client should the charge nurse assign to the licensed practical nurse (LPN)?
- A. The client with pneumonia who has a pulse oximeter reading of 91%.
- B. The client with a hemothorax who has Hb of 9 g/dL and Hct of 20%.
- C. The client with chest tubes who has jugular vein distention and BP of 96/60.
- D. The client who is two (2) hours post-bronchoscopy procedure.
Correct Answer: D
Rationale: Post-bronchoscopy (D) is stable for LPN care. Hypoxia (A), anemia (B), and JVD/hypotension (C) require RN assessment.