Nokea
The nurse has finished suctioning the tracheostomy of a client. Which parameter should the nurse monitor to determine the effectiveness of the procedure?
- A. Breath sounds
- B. Capillary refill
- C. Respiratory rate
- D. Oxygen saturation level
Correct Answer: A
Rationale: After suctioning a client either with or without an artificial airway, the breath sounds are auscultated to determine the extent to which the airways have been cleared of respiratory secretions. The other assessment items are not as precise as breath sounds for this purpose.
You may also like to solve these questions
A client with a history of chronic kidney disease is prescribed sodium polystyrene sulfonate (Kayexalate). The nurse should explain that this medication works by:
- A. Reducing blood pressure.
- B. Binding potassium in the gut.
- C. Increasing urine output.
- D. Decreasing blood glucose.
Correct Answer: B
Rationale: Sodium polystyrene sulfonate binds potassium in the gut, reducing serum potassium levels in chronic kidney disease.
The nurse is caring for a client with a history of deep vein thrombosis (DVT). Which of the following laboratory values should the nurse monitor?
- A. Activated partial thromboplastin time (aPTT).
- B. Prothrombin time (PT).
- C. International normalized ratio (INR).
- D. D-dimer.
Correct Answer: A, D
Rationale: aPTT monitors heparin therapy, and D-dimer indicates clot presence in DVT.
A registered nurse (RN) is supervising a licensed practical nurse (LPN) providing care to a client with end-stage heart failure. The client is withdrawn, is reluctant to talk, and shows little interest in participating in hygienic care or activities. Which statement by the LPN to the client indicates that the LPN needs further teaching in the use of therapeutic communication skills?
- A. You are very quiet today.
- B. What are your feelings right now?
- C. Why don't you feel like getting up?
- D. Tell me more about your difficulty with sleeping at night.
Correct Answer: C
Rationale: When a 'why' question is made to the client, an explanation for feelings and behaviors is requested, and the client may not know the reason. Requesting an explanation is a nontherapeutic communication technique. In option 1, the LPN is using the therapeutic communication technique of acknowledging the client's behavior. In option 2, the LPN is encouraging identification of emotions or feelings. In option 4, the LPN is using the therapeutic communication technique of exploring, which is asking the client to describe something in more detail or to discuss it more fully.
The registered nurse, prior to the delegation of tasks to other members of the nursing care team, evaluates the ability of staff members to perform assigned tasks for the position as based on which legal consideration?
- A. The American Nurses Association's Scopes of Practice
- B. The American Nurses Association's Standards of Care
- C. State statutes
- D. Federal law
Correct Answer: C
Rationale: Delegation of tasks by a registered nurse must comply with state statutes , which define the scope of practice and delegation authority for nurses and other healthcare team members within each state. These laws ensure that tasks are delegated to individuals who are legally qualified to perform them.
A client with the diagnosis of pneumonia experiences dyspnea when engaging activities. Which action should the nurse implement to help address client safety?
- A. Encourage deep, rapid breathing during activity.
- B. Provide stimulation in the environment to maintain client alertness.
- C. Observe vital signs and oxygen saturation periodically during activity.
- D. Schedule activities before giving respiratory medications or treatments.
Correct Answer: C
Rationale: Monitoring vital signs and oxygen saturation during activity ensures the nurse can detect early signs of respiratory distress or hypoxia, promoting client safety. Encouraging deep, rapid breathing may exacerbate dyspnea and is not safe. Providing environmental stimulation is unrelated to respiratory safety. Scheduling activities before respiratory medications or treatments could worsen dyspnea, as these interventions improve breathing capacity.