Nokea
During orientation, a newly hired nurse demonstrates suctioning of a tracheostomy in a skills class. After the demonstration, the supervising nurse expresses concern that the demonstrated procedure increased the client's risk for which problem?
- A. Infection
- B. Hypoxia
- C. Bleeding
- D. Bronchospasm
Correct Answer: A
Rationale: The correct answer is A: Infection. Improper suctioning techniques can introduce pathogens, increasing the risk of infection. Choice B, Hypoxia, is incorrect as it is more related to inadequate oxygen supply. Choice C, Bleeding, is not typically associated with suctioning a tracheostomy unless done too aggressively. Choice D, Bronchospasm, is not directly linked to suctioning but may occur due to other triggers in patients with sensitive airways.
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The nurse is assessing a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which laboratory value should be closely monitored?
- A. Serum potassium level
- B. Hemoglobin level
- C. White blood cell count
- D. Serum sodium level of 135 mEq/L
Correct Answer: A
Rationale: The correct answer is A: Serum potassium level. In clients receiving erythropoietin therapy for chronic kidney disease, monitoring serum potassium levels is crucial due to the risk of developing hyperkalemia. Erythropoietin therapy can stimulate red blood cell production, leading to an increase in potassium levels. Monitoring potassium levels helps prevent complications associated with hyperkalemia, such as cardiac arrhythmias. Choices B, C, and D are incorrect because while hemoglobin levels are relevant for assessing the effectiveness of erythropoietin therapy, monitoring potassium levels is more critical due to the potential adverse effects of elevated potassium levels in CKD patients on this therapy.
Sublingual nitroglycerin is administered to a male client with unstable angina who complains of crushing chest pain. Five minutes later the client becomes nauseated, and his blood pressure drops to 60/40. Which intervention should the nurse implement?
- A. Administer a second dose of nitroglycerin.
- B. Infuse a rapid IV normal saline bolus.
- C. Begin external chest compressions.
- D. Give a PRN antiemetic medication.
Correct Answer: B
Rationale: In this scenario, the client's symptoms of nausea and a significant drop in blood pressure suggest a potential right ventricular infarction. The appropriate intervention for this situation is to infuse a rapid IV normal saline bolus. This fluid resuscitation helps improve cardiac output by increasing preload, which can be beneficial in right ventricular infarction. Administering a second dose of nitroglycerin may further lower blood pressure. External chest compressions are not indicated in this case as the client has a pulse. Providing an antiemetic medication does not address the underlying issue of hypotension and potential right ventricular involvement.
The nurse is teaching a male client with multiple sclerosis how to empty his bladder using the Crede Method. When performing a return demonstration, the client applies pressure to the umbilical areas of his abdomen. What instruction should the nurse provide?
- A. Stroke the inner thigh below the perineum to initiate urinary flow
- B. Contract, hold, and then relax the pubococcygeal muscle
- C. Pour warm water over the external sphincter at the distal glans
- D. Apply downward manual pressure at the suprapubic regions
Correct Answer: D
Rationale: The client is applying pressure in the wrong region (umbilical area) and should be instructed to apply pressure at the suprapubic area. Applying downward manual pressure at the suprapubic region helps in emptying the bladder effectively by assisting in pushing the urine out through the urethra. Choices A, B, and C are incorrect because they do not address the specific issue of applying pressure to help empty the bladder using the Crede Method.
The nurse is caring for a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which laboratory value should be closely monitored?
- A. Serum potassium level
- B. Hemoglobin level
- C. White blood cell count
- D. Serum calcium level
Correct Answer: A
Rationale: The correct answer is A: Serum potassium level. When a client with chronic kidney disease is receiving erythropoietin therapy, monitoring serum potassium levels is crucial due to the risk of developing hyperkalemia. Erythropoietin can stimulate red blood cell production, leading to an increase in potassium levels. Monitoring potassium helps prevent complications associated with hyperkalemia, such as cardiac arrhythmias. Choices B, C, and D are incorrect because while hemoglobin levels are relevant in assessing the effectiveness of erythropoietin therapy, monitoring potassium levels is more critical in this scenario.
What is the most important instruction for the nurse to provide a client being discharged following treatment for Guillain-Barre syndrome?
- A. Avoid exposure to respiratory infections.
- B. Use relaxation exercises when anxious.
- C. Continue physical therapy at home.
- D. Plan short, frequent rest periods.
Correct Answer: A
Rationale: The most critical instruction for a client being discharged following treatment for Guillain-Barre syndrome is to avoid exposure to respiratory infections. Guillain-Barre syndrome can affect the respiratory system, making infections particularly dangerous. While relaxation exercises, physical therapy, and rest periods are beneficial for overall well-being and recovery, preventing respiratory infections takes precedence due to the potential life-threatening complications associated with respiratory compromise in Guillain-Barre syndrome.