Nokea
Complications associated with a tracheostomy tube include:
- A. Decreased cardiac output.
- B. Damage to the laryngeal nerve.
- C. Pneumothorax.
- D. Acute respiratory distress syndrome (ARDS).
Correct Answer: C
Rationale: Pneumothorax is a potential complication of tracheostomy tube placement due to possible injury to the lung or pleural space during insertion or maintenance.
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A nurse is developing a care plan for a client with hepatic encephalopathy. Which of the following are goals for the care for this client? Select all that apply.
- A. Preventing constipation.
- B. Administering lactulose (Cephulac).
- C. Monitoring coordination while walking.
- D. Checking the pupil reaction.
- E. Increasing food and fluids high in carbohydrate.
- F. Encouraging physical activity.
Correct Answer: A,B
Rationale: Preventing constipation (A) and administering lactulose (B) reduce ammonia levels, key in managing hepatic encephalopathy. Coordination (C) and pupil reaction (D) are unrelated. High carbohydrates (E) and physical activity (F) are not primary goals.
A client is admitted with a 6.5-cm thoracic aneurysm. The nurse records findings from the initial assessment in the client's chart, as shown below. At 10:30 a.m., the client complains of sharp midchest pain after having a bowel movement. What should the nurse do first?
- A. Assess the client's vital signs
- B. Administer a bolus of lactated Ringer's solution
- C. Assess the client's neurologic status
- D. Contact the physician
Correct Answer: A
Rationale: Sharp midchest pain in a client with a thoracic aneurysm suggests possible dissection or rupture, a life-threatening emergency. Assessing vital signs (e.g., hypotension, tachycardia) first provides critical data to guide action. Fluid bolus, neurologic assessment, or contacting the physician follow based on findings.
A client who has had her jaws wired begins to vomit. What should be the nurse's first action?
- A. Insert a nasogastric (NG) tube and connect it to suction.
- B. Use wire cutters to cut the wire.
- C. Suction the client's airway as needed.
- D. Administer an antiemetic intravenously.
Correct Answer: C
Rationale: Suctioning the airway is the first action to prevent aspiration in a client with wired jaws who is vomiting. Cutting the wires is a last resort, and the other options do not address the immediate risk of airway obstruction.
The nurse anticipates that the client who has received epidural anesthesia is at decreased risk for a spinal headache because:
- A. A 17G needle is used.
- B. A subarachnoid injection is made.
- C. A noncutting needle is used.
- D. A faster onset occurs.
Correct Answer: C
Rationale: Epidural anesthesia uses a noncutting needle, reducing dural puncture risk and thus lowering the incidence of spinal headache compared to spinal anesthesia.
The nurse receives emergency laboratory results for a client with chest pain and immediately informs the physician. An increased myoglobin level suggests which of the following?
- A. Cancer.
- B. Hypertension.
- C. Liver disease.
- D. Myocardial damage.
Correct Answer: D
Rationale: Elevated myoglobin indicates myocardial damage, as it is released from injured cardiac muscle, supporting a diagnosis of MI.