Nokea
The nurse inserting an oropharyngeal airway into an assigned client should plan to use which insertion procedure?
- A. Flexing the client's neck
- B. Leaving dentures in place
- C. Suctioning the client's mouth only if prescribed
- D. Inserting the airway with the tip pointed upward
Correct Answer: D
Rationale: The airway is inserted with the tip pointed upward and is then rotated downward once the flange has reached the client's teeth. The client should be positioned supine, with the neck hyperextended if possible. Before insertion of an oropharyngeal airway, any dentures or partial plates should be removed from the client's mouth. After insertion, the client's mouth is suctioned every hour or as necessary. The airway is removed for inspection of the mouth every 2 to 4 hours.
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A postoperative client is prescribed incentive spirometry. What is the primary purpose of this intervention?
- A. Prevent atelectasis.
- B. Reduce incisional pain.
- C. Improve circulation.
- D. Promote wound healing.
Correct Answer: A
Rationale: Incentive spirometry encourages deep breathing to expand alveoli, preventing atelectasis after surgery.
The nurse is teaching a client with a new colostomy about dietary management. Which of the following foods should the nurse recommend to prevent odor and gas?
- A. Yogurt.
- B. Broccoli.
- C. Eggs.
- D. Beans.
Correct Answer: A
Rationale: Yogurt contains probiotics that can reduce gas and odor in colostomy output, unlike broccoli, eggs, or beans, which may increase gas.
After instructing a primiparous client who is breast-feeding on how to prevent nipple soreness during feedings, the nurse determines that the client needs further instruction when she states which of the following?
- A. I should position the baby the same way for each feeding.'
- B. I should make sure the baby grasps the entire areola and nipple.'
- C. I should air dry my breasts and nipples for 10 to 15 minutes after the feeding.'
- D. I shouldn't use a hand breast pump if my nipples get sore.'
Correct Answer: A
Rationale: Varying the baby's position during feeding prevents nipple soreness, so using the same position indicates a need for further instruction.
The nurse is caring for a preterm neonate in the NICU. Which intervention is essential to prevent retinopathy of prematurity?
- A. Monitor oxygen saturation
- B. Administer vitamin D
- C. Provide high-calorie formula
- D. Keep the incubator at 37°C
Correct Answer: A
Rationale: Excessive oxygen can contribute to retinopathy of prematurity in preterm neonates. Monitoring oxygen saturation ensures levels remain within a safe range.
A client is scheduled for an intravenous pyelogram (IVP). Which of the following questions would be most important for the nurse to ask the client in preparation for the procedure?
- A. Have you ever had an IVP before?'
- B. Do you have any allergies to shellfish?'
- C. When was your last bowel movement?'
- D. Have you ever experienced urinary incontinence?'
Correct Answer: B
Rationale: Shellfish allergies may indicate a risk for contrast dye reactions, critical for IVP safety.