Nokea
The nurse is caring for a client with a new tracheostomy. Which action is the priority during routine care?
- A. Suction the tracheostomy every 4 hours.
- B. Clean the stoma site with sterile saline.
- C. Change the tracheostomy ties daily.
- D. Monitor for signs of infection.
Correct Answer: B
Rationale: Cleaning the stoma site with sterile saline prevents infection and maintains skin integrity, making it the priority during routine tracheostomy care.
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An adult client has been placed on a fluid restriction of 1200 mL per day. The nurse discusses the fluid restriction with the dietitian and then plans to allow the client to have how many milliliters of fluid from 7:00 am to 3:00 pm?
- A. 400 mL
- B. 600 mL
- C. 800 mL
- D. 1000 mL
Correct Answer: B
Rationale: When a client is on fluid restriction, the nurse informs the dietary department and discusses the allotment of fluid per shift with the dietitian. When calculating how to distribute a fluid restriction, the nurse usually allows half of the daily allotment (600 mL) during the day shift, when the client eats two meals and takes most medications. Another two-fifths (480 mL) is allotted to the evening shift, with the balance (120 mL) allowed during the nighttime.
While assessing the fundus of a multiparous client on the first postpartum day, the nurse performs handwashing and dons clean gloves. Which of the following should the nurse do next?
- A. Place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus.
- B. Ask the client to assume a side-lying position with the knees flexed.
- C. Perform massage vigorously at the level of the umbilicus if the fundus feels boggy.
- D. Place the client on a bedpan in case the uterine palpation stimulates the client to void.
Correct Answer: A
Rationale: This technique stabilizes the uterus during fundus assessment, preventing discomfort and ensuring accurate palpation.
The nurse is assessing a teenage girl. According to the fi gure below, the nurse should note that the girl has:
- A. Kyphosis.
- B. Arthritis.
- C. Developmental dysplasia of the hip.
- D. Scoliosis.
Correct Answer: D
Rationale: The teenage girl has scoliosis, the lateral deviation of the spine. Kyphosis is noted by a forward curvature of the shoulders. Arthritis is diagnosed by radiographs. Hip dysplasia is noted in older children by pain, but is usually diagnosed before the child walks by noting excessive gluteal folds and limited hip abduction.
The nurse is caring for an elderly client who has hip pain related to rheumatoid arthritis. The client is practicing appropriate self-care activities when she chooses to sit in which of the following chairs?
- A. Recliner chair with arms to support wrists and hands.
- B. Couch with soft cushions to support thighs.
- C. Straight-back chair with elevated seat.
- D. Curved-back rocking chair.
Correct Answer: C
Rationale: A straight-back chair with an elevated seat reduces joint strain and supports proper posture, ideal for rheumatoid arthritis. Other options may exacerbate pain or lack support.
When assessing speech development, which of the following children should the nurse refer for further examination?
- A. A 4-month-old who laughs out loud.
- B. A 10-month-old who says 'dada' and 'mama.'
- C. A 1-year-old who says 3 to 5 words.
- D. An 18-month-old who only says 'no.'
Correct Answer: D
Rationale: An 18-month-old should have a vocabulary of about 15-20 words and start forming simple phrases. Only saying 'no' indicates a potential delay, warranting further evaluation. The other options reflect age-appropriate speech milestones.