The nurse is caring for a 6-month-old client who has a new tracheostomy. Which of the following findings would indicate that the client's airway requires suctioning? Select all that apply.
- A. Audible gurgling
- B. Heart rate of 110/min
- C. Increased irritability
- D. Oxygen saturation of 88%
- E. Respiratory rate of 30/min
Correct Answer: A,C,D
Rationale: Audible gurgling, irritability, and low oxygen saturation (88%) indicate airway obstruction or secretions requiring suctioning. Normal heart rate (110/min) and respiratory rate (30/min) for a 6-month-old do not necessitate suctioning.
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The nurse is assessing a comatose client receiving gastric tube feedings. Which of the following assessments requires an immediate response from the nurse?
- A. Decreased breath sounds in right lower lobe
- B. Aspiration of a residual of 100 cc of formula
- C. Decrease in bowel sounds
- D. Urine output of 250 cc in past 8 hours
Correct Answer: A
Rationale: Decreased breath sounds in right lower lobe. The most common problem associated with enteral feedings is atelectasis. Maintain client at 30 degrees of head elevation during feedings and monitor for signs of aspiration. Check for tube placement prior to each feeding or every 4 to 8 hours if the client is receiving continuous feeding.
A client is scheduled for a percutaneous kidney biopsy at 1000. The practical nurse reviews the client's vital signs and most current serum laboratory results at 0600. Which of the following client findings is most important to report to the registered nurse?
- A. hemoglobin of 9.8 g/dL (98 g/L)
- B. blood pressure of 180/100 mm Hg
- C. creatinine of 2.0 mg/dL (177 µmol/L)
- D. platelet count of 120,000/mm³ (120 × 10â¹/L)
Correct Answer: B
Rationale: Severe hypertension (180/100 mm Hg) increases bleeding risk during a kidney biopsy, requiring immediate reporting. Other findings are concerning but less urgent.
The nurse is attending an end-of-year school family picnic. Which situation needs an immediate intervention?
- A. A 2-year-old eating a hot dog unsupervised
- B. A 3-year-old playing alone in a wading pool
- C. A 4-year-old tossing a beach ball
- D. A 5-year-old climbing on monkey bars
Correct Answer: B
Rationale: A 3-year-old alone in a wading pool is at immediate risk of drowning, requiring urgent intervention. A poses a choking risk but is less immediately life-threatening. C and D are age-appropriate activities with lower immediate risk.
The nurse is reinforcing teaching for a client with heart failure who has had multiple admissions to treat exacerbations. Which of the following statements by the client would require follow-up?
- A. I will begin weighing myself at the same time every day.
- B. I will eat foods high in potassium while taking furosemide.
- C. I will prepare frozen meals at home instead of eating restaurant foods.
- D. I will start incorporating moderate exercise into my daily routine.
Correct Answer: B
Rationale: High-potassium foods can cause hyperkalemia in heart failure patients, especially with certain medications, requiring follow-up. Other statements are appropriate.
Which actions by a nurse are reportable to the state board of nursing? Select all that apply.
- A. Administering hydromorphone without a prescription
- B. Being habitually tardy to work
- C. Documenting an intervention that was not performed
- D. Stealing narcotics
- E. Walking off duty in the middle of a shift
Correct Answer: A,C,D
Rationale: Administering medication without a prescription, falsifying documentation, and stealing narcotics are reportable to the state board. Tardiness and leaving a shift are not typically reportable.