Nokea
The nurse is caring for a client with a new tracheostomy.
- A. What is the priority nursing intervention for a client with a new tracheostomy?
- B. Suction the tracheostomy every 2 hours.
- C. Change the tracheostomy ties daily.
- D. Monitor the stoma for signs of infection.
- E. Keep the tracheostomy cuff inflated at all times.
Correct Answer: C
Rationale: Monitoring the stoma for signs of infection is the priority to detect complications early, ensuring airway safety. Suctioning is as needed, ties are changed as needed, and continuous cuff inflation risks tracheal damage.
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A client is admitted with a diagnosis of trigeminal neuralgia (tic douloureux) involving the maxillary branch of the affected nerve. When performing client teaching, it is MOST important for the nurse to include which of the following instructions?
- A. Report an increase in blurred vision.
- B. Eat soft, warm foods.
- C. Change positions slowly.
- D. Chew food on the affected side.
Correct Answer: B
Rationale: intense facial pain experienced along nerve tract is characteristic of this condition; nursing care should be directed toward preventing stimuli to the area and decreasing pain
A client who has been abusing alcohol and other drugs for six years. The nursing diagnosis is ineffective individual coping.
Which of the following nursing actions should take priority during the working stage of their relationship?
- A. Observe the client every half-hour to determine the extent of drug-seeking behavior.
- B. Monitor the intake of fluids, meals, and snacks to ensure adequate nutrition.
- C. Help the client obtain a sponsor through a 12-step group in the client's local area.
- D. Meet individually with the client to discuss the consequences of drug-using behavior and examine other options.
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Are the assessments appropriate? No. Determine the outcome of the implementations. (1) assessment, important in the assessment phase of the relationship (2) assessment, important for a different nursing diagnosis (3) implementation, will be important in discharge planning (4) correct-implementation, describes the work of the interpersonal relationship with a chemically dependent client; goal is to get client to recognize problems the chemicals have caused and to learn new methods of solving problems
The nurse is caring for a 74-year-old man with type I diabetes. The client is scheduled for cataractsurgery under general anesthesia at 9 AM. The man usually receives 30 units of NPH and 10 units of regular insulin each morning at 7 AM. At 7 AM the morning of surgery, the nurse would expect to take which of the following actions?
- A. hold the morning dose of NPH and regular insulin and monitor the blood glucose.
- B. give half the morning dose of NPH insulin along with the regular insulin and monitor the blood glucose when the client returns from surgery.
- C. give the full dose of NPH and regular insulin and monitor the blood glucose every 2 to 4 hours.
- D. give the full dose of regular insulin but hold the NPH insulin and monitor the blood glucose until the client goes to surgery.
Correct Answer: A
Rationale: usually use sliding scale with regular insulin based on blood glucose readings
The physician orders meperidine (Demerol) 50 mg IM every 3-4 h PRN for pain for a client. The client asks the nurse for the medication at bedtime. Prior to administering the pain medication, the nurse should
- A. take measures to determine if the pain is psychological.
- B. check to see if the man has a history of addiction.
- C. try several other comfort and pain relief measures.
- D. learn the location, character, and intensity of the pain.
Correct Answer: D
Rationale: assessment first step in nursing process
A patient is returned to his room following an appendectomy. The nurse notices a large amount of serosanguineous drainage on the dressing. It is MOST important for the nurse to obtain an answer to which of the following questions?
- A. Were there any intraoperative complications?
- B. Has the dressing been changed?
- C. Why didn't the recovery room nurse report any drainage?
- D. Was a tissue drain placed during surgery?
Correct Answer: D
Rationale: drain is frequently placed during surgery to prevent accumulation in wound, dressing should be reinforced