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.
You may also like to solve these questions
A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. Which assessment finding requires immediate intervention?
- A. Barrel-shaped chest
- B. Use of accessory muscles
- C. Oxygen saturation of 85%
- D. Inspiratory crackles
Correct Answer: C
Rationale: An oxygen saturation of 85% is significantly low for a client with COPD and requires immediate intervention to prevent hypoxemia. Oxygen saturation below 90% indicates poor oxygenation and poses a risk of tissue hypoxia, making it a critical finding that needs prompt attention. Barrel-shaped chest and inspiratory crackles are commonly seen in clients with COPD and do not necessitate immediate intervention. The use of accessory muscles may indicate increased work of breathing but does not pose the same level of immediate threat as severe hypoxemia.
The mother of a one-month-old boy born at home brings the infant to his first well-baby visit. She mentions that he was born two weeks after his due date and is a 'good, quiet baby' who almost never cries. To assess for hypothyroidism, what question is most important for the nurse to ask the mother?
- A. Has your son had any immunizations yet?
- B. Is your son sleepy and difficult to feed?
- C. Are you breastfeeding or bottle feeding your son?
- D. Were any relatives born with birth defects?
Correct Answer: B
Rationale: The correct answer is B. Sleepiness and difficulty feeding are key signs of congenital hypothyroidism, which requires early diagnosis and treatment. Asking about immunizations (choice A) is important but not directly related to assessing hypothyroidism. The feeding method (choice C) is relevant for overall health but not specific to hypothyroidism. Inquiring about relatives with birth defects (choice D) is not the most crucial question to assess hypothyroidism in this scenario.
A client with acute pancreatitis is admitted with severe abdominal pain. Which assessment finding requires immediate intervention?
- A. Severe abdominal distention
- B. Decreased urine output
- C. Decreased bowel sounds
- D. Increased heart rate
Correct Answer: A
Rationale: Severe abdominal distention is a sign of worsening pancreatitis and can indicate complications like bowel obstruction or fluid accumulation. Immediate intervention is necessary to prevent further deterioration. Decreased urine output (Choice B) could indicate renal impairment, decreased bowel sounds (Choice C) are expected in pancreatitis due to paralytic ileus, and an increased heart rate (Choice D) is a common response to pain or stress in acute pancreatitis but may not require immediate intervention unless it is extremely high or persistent.
While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?
- A. Elevated blood pressure must be anticipated and identified quickly
- B. Frequent monitoring helps ensure the medication is effective
- C. It is standard protocol for all hospitalized children
- D. We need to monitor for any potential kidney damage
Correct Answer: A
Rationale: The correct answer is A: 'Elevated blood pressure must be anticipated and identified quickly.' Acute glomerulonephritis can lead to significant hypertension, making it crucial to monitor blood pressure frequently to promptly identify any elevation. Choice B is incorrect because while monitoring can help assess medication effectiveness, the primary reason for frequent blood pressure checks in this case is to detect elevated blood pressure. Choice C is incorrect as not all hospitalized children require such frequent blood pressure monitoring. Choice D is incorrect as the primary reason for monitoring blood pressure is to detect hypertension, rather than solely focusing on potential kidney damage.
A client is admitted with a diagnosis of sepsis. Which assessment finding is most concerning to the nurse?
- A. Temperature of 101.5°F
- B. Heart rate of 110 beats per minute
- C. Respiratory rate of 24 breaths per minute
- D. Blood pressure of 90/60 mmHg
Correct Answer: D
Rationale: A blood pressure of 90/60 mmHg in a client with sepsis is concerning for septic shock, a life-threatening condition that requires immediate intervention. Hypotension is a severe manifestation of sepsis that can lead to poor tissue perfusion and organ failure. While the other assessment findings such as an elevated temperature, increased heart rate, and respiratory rate are also common in sepsis, hypotension is particularly alarming as it indicates a critical state of shock and necessitates urgent medical attention.