Nokea
The nurse is caring for a client with a history of burns. Which of the following nutritional interventions should be included in the plan of care?
- A. High-protein, high-calorie diet.
- B. Low-sodium diet.
- C. Low-fat diet.
- D. High-fiber diet.
Correct Answer: A
Rationale: A high-protein, high-calorie diet supports tissue repair and energy needs in burn recovery.
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A client with a history of osteoporosis is prescribed alendronate (Fosamax). The nurse should instruct the client to:
- A. Take it with meals
- B. Remain upright for 30 minutes after taking
- C. Take it at bedtime
- D. Crush the tablet for easier swallowing
Correct Answer: B
Rationale: Remaining upright for 30 minutes after taking alendronate prevents esophageal irritation and enhances absorption.
The nurse is preparing to suction an adult client with a tracheostomy who has copious amounts of secretions. Which action should the nurse take to accomplish this procedure safely and effectively?
- A. Hyperoxygenate the client after the procedure only.
- B. Apply continuous suction in the airway for up to 20 seconds.
- C. Set the wall suction pressure range between 80 and 120 mm Hg.
- D. Occlude the Y-port of the catheter while advancing it into the tracheostomy.
Correct Answer: C
Rationale: The safe wall suction range for an adult is 80 to 120 mm Hg, making option 3 the action that is consistent with safe and effective practice. The nurse should hyperoxygenate the client both before and after suctioning. The nurse should use intermittent suction in the airway (not constant) for up to 10 to 15 seconds. The nurse should advance the catheter into the tracheostomy without occluding the Y-port to minimize mucosal trauma and aspiration of the client's oxygen.
Thirty minutes after a Sengstaken-Blakemore tube is inserted, the nurse observes that the client appears to be having difficulty breathing. The nurse's first action should be to:
- A. Remove the tube.
- B. Deflate the esophageal portion of the tube.
- C. Determine whether the tube is obstructing the airway.
- D. Increase the oxygen flow rate.
Correct Answer: C
Rationale: Difficulty breathing may indicate airway obstruction by the Sengstaken-Blakemore tube, so assessing this is the priority action.
A client's 12:00 noon blood glucose concentration was inaccurately documented as 310 instead of 130. This error was not noticed until 1:00 p.m. The nurse administered the sliding scale insulin for a blood glucose of 310 instead of 130. What should the nurse do first?
- A. Notify the physician.
- B. Assess for hypoglycemia.
- C. Consult with the clinical pharmacist.
- D. Call the charge nurse.
Correct Answer: B
Rationale: Administering insulin for a falsely high glucose level risks hypoglycemia, so assessing for symptoms (e.g., shakiness, sweating) is the priority.
Which of the following is NOT an essential component of a restraint order?
- A. Informed consent for the restraint
- B. The reason for the restraint
- C. The type of restraint to be used
- D. Client behaviors that necessitated the restraints
Correct Answer: A
Rationale: A restraint order requires the reason , type , and client behaviors necessitating the restraint . Informed consent is not typically required for restraints, as they are used in emergencies or for safety.