Nokea
The nurse is caring for a client with a permanent tracheostomy who is able to eat. Which is the correct action by the nurse in managing this tube?
- A. if the tube must be capped, place the cap before deflating the cuff
- B. inflate the cuff and remove the inner cannula before capping the tube
- C. inflate the cuff (if the tube is not capped) for meals and 1 hour afterward to prevent aspiration
- D. deflate the cuff (if the tube is not capped) for meals and 1 hour afterward to prevent aspiration
Correct Answer: D
Rationale: Deflating the cuff during meals allows normal swallowing, reducing aspiration risk, and is maintained for 1 hour post-meal.
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The nurse is caring for a client with dementia who tends to wander. Which of the following actions can help with this behavior? Select all that apply.
- A. providing frequent toileting or incontinence care as needed
- B. assessing client for pain and treat with appropriate medications
- C. reorienting the client and use validation therapy, as appropriate
- D. allowing the client to sit in a recliner at the nurses' station for close monitoring
- E. using chemical or physical restraints to prevent the client from exiting the bed
Correct Answer: A, B, C, D
Rationale: Frequent toileting, pain management, reorientation, and close monitoring address wandering causes and promote safety. Restraints are a last resort and not ideal for wandering.
The client has a prescription for a calcium carbonate compound to neutralize stomach acid. The nurse should assess the client for:
- A. Constipation
- B. Hyperphosphatemia
- C. Hypomagnesemia
- D. Diarrhea
Correct Answer: A
Rationale: Calcium carbonate can cause constipation, a common side effect, due to its effect on gastrointestinal motility.
A gravida III para II is admitted to the labor unit. Vaginal exam reveals that the client's cervix is 8 cm dilated, with complete effacement. The priority nursing diagnosis at this time is:
- A. Alteration in coping related to pain
- B. Potential for injury related to precipitate delivery
- C. Alteration in elimination related to anesthesia
- D. Potential for fluid volume deficit related to NPO status
Correct Answer: B
Rationale: At 8 cm dilation with complete effacement, the client is in advanced labor, and the risk of precipitate delivery is high, posing a potential for injury.
Which finding is the best indication that a client with ineffective airway clearance needs suctioning?
- A. Oxygen saturation
- B. Respiratory rate
- C. Breath sounds
- D. Arterial blood gases
Correct Answer: C
Rationale: Adventitious breath sounds (e.g., rhonchi or gurgling) indicate mucus obstruction, making suctioning necessary to clear the airway.
The nurse is caring for a client receiving theophylline for asthma. In reviewing client labs, the nurse understands that the dose is therapeutic when the drug level is at what concentration?
- A. 0.8-2 mcg/L
- B. 10-20 mg/L
- C. 10-20 mcg/mL
- D. 0.8-12 mmol/L
Correct Answer: C
Rationale: The therapeutic range for theophylline is 10-20 mcg/mL. Other ranges are incorrect for this medication.