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During suctioning of a tracheostomy tube, the catheter appears to attach to the tracheal wall and creates a pulling sensation. What is the best action for the nurse to take?
- A. Release the suction by opening the vent
- B. Continue suctioning to remove the obstruction
- C. Increase the pressure
- D. Suction deeper
Correct Answer: A
Rationale: Releasing suction by opening the vent prevents trauma to the tracheal mucosa when the catheter adheres to the wall.
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The client diagnosed with restrictive airway disease (asthma) has been prescribed a glucocorticoid inhaled medication. Which information should the nurse teach regarding this medication?
- A. Do not abruptly stop taking this medication; it must be tapered off.
- B. Immediately rinse the mouth following administration of the drug.
- C. Hold the medication in the mouth for 15 seconds before swallowing.
- D. Take the medication immediately when an attack starts.
Correct Answer: B
Rationale: Rinsing the mouth (B) prevents oral thrush from inhaled glucocorticoids. Tapering (A) applies to systemic steroids, holding/swallowing (C) is incorrect, and attack use (D) is for rescue inhalers.
The client diagnosed with deep vein thrombosis (DVT) suddenly complains of severe chest pain and a feeling of impending doom. Which complication should the nurse suspect the client has experienced?
- A. Myocardial infarction.
- B. Pneumonia.
- C. Pulmonary embolus.
- D. Pneumothorax.
Correct Answer: C
Rationale: Sudden chest pain and impending doom in a DVT patient suggest pulmonary embolus (C), where a clot dislodges to the lungs, causing acute respiratory distress. Myocardial infarction (A) presents with cardiac symptoms. Pneumonia (B) has gradual onset. Pneumothorax (D) causes unilateral symptoms.
Which nursing intervention is most important in response to the client's physical symptoms at this time?
- A. Administering oxygen by face mask
- B. Assessing the client's capillary refill
- C. Having the client rate the pain on a pain scale
- D. Requesting a physician's order for cardiac enzymes
Correct Answer: A
Rationale: Administering oxygen addresses hypoxia, a critical concern in pulmonary embolism due to impaired gas exchange.
The school nurse is presenting a class to students at a primary school on how to prevent the transmission of the common cold virus. Which information should the nurse discuss?
- A. Instruct the children to always keep a tissue or handkerchief with them.
- B. Explain that children current with immunizations will not get a cold.
- C. Tell the children they should go to the doctor if they get a cold.
- D. Demonstrate to the students how to wash hands correctly.
Correct Answer: D
Rationale: Handwashing (D) is the most effective way to prevent cold transmission. Tissues (A) are secondary, immunizations (B) don’t prevent colds, and doctor visits (C) are unnecessary for most colds.
The nurse is planning the care of a client diagnosed with pneumonia and writes a problem of 'impaired gas exchange.' Which is an expected outcome for this problem?
- A. Performs chest physiotherapy three (3) times a day.
- B. Able to complete activities of daily living.
- C. Ambulates in the hall several times during each shift.
- D. Alert and oriented to person, place, time, and events.
Correct Answer: D
Rationale: Alert/oriented status (D) indicates improved oxygenation from resolved gas exchange impairment. Physiotherapy (A) is an intervention, ADLs (B) and ambulation (C) are secondary outcomes.