Nokea
The nurse is caring for a client with a tracheostomy receiving oxygen therapy. Which intervention should the nurse prioritize to prevent infection and ensure proper oxygen delivery?
- A. Regularly suctioning the tracheostomy tube
- B. Assessing the client's respiratory rate every hour
- C. Applying a sterile dressing over the tracheostomy site
- D. Administering humidified oxygen through the tracheostomy tube
Correct Answer: C
Rationale: Applying a sterile dressing over the tracheostomy site helps prevent infection by providing a barrier against microorganisms. It also ensures a clean environment for optimal oxygen delivery and promotes wound healing.
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A nurse is talking with an older adult client who is contemplating retirement. The client states, 'I keep thinking about how much I enjoy my job. I’m not sure I want to retire'. Which of the following responses should the nurse make?
- A. You would have so much more time to spend with your family
- B. You should consider getting a part-time job or doing volunteer work
- C. Let’s talk about how the change in your job status will affect you
- D. Why wouldn’t you want to retire and relax?
Correct Answer: C
Rationale: Let’s talk about how the change in your job status will affect you.
During an admission assessment a client responds with rhyming statements such as 'tip, rip, dip and hip'. The nurse recognizes this speech pattern is associated with which mental health disorder?
- A. Mania
- B. Anxiety
- C. Depression
- D. Schizophrenia
Correct Answer: D
Rationale: This speech pattern is associated with psychotic disorders and schizophrenia. The client is exhibiting a type of speech called Clang association which is the meaningless rhyming of words, often in a forceful manner.
A nurse is reinforcing teaching with the parents of a child who is starting to use a spacer with a metered-dose inhaler (MDI) to treat asthma. Which of the following information should the nurse include in the teaching?
- A. The spacer increases the amount of medication delivered to the oropharynx.
- B. Cover exhalation slots of the spacer with lips when inhaling.
- C. The spacer increases the amount of medication delivered to the lungs.
- D. Inhale rapidly when using the spacer with the MDI.
Correct Answer: C
Rationale: The spacer helps to deliver more medication to the lungs by holding the medication in the chamber, allowing the patient to inhale it more slowly and deeply. This results in better deposition of the medication in the lower airways and reduces the amount of medication that is deposited in the mouth and throat.
The nurse is assessing an older client. What effects of aging should the nurse keep in mind during this assessment?
- A. Decreased cough reflex
- B. Stiffening of blood vessels
- C. Alteration in protein synthesis
- D. Dry mucous membranes
Correct Answer: A
Rationale: E (Decreased cough reflex Dry mucous membranes Increased risk of aspiration) Aging reduces cough reflex (A) increasing aspiration risk (E) and dries mucous membranes (D) impairing airway clearance. Stiffening of blood vessels (B) affects cardiovascular health not respiratory. Altered protein synthesis (C) is nonspecific and unrelated making A
A client has a medical condition that often results in the development of metabolic acidosis. The nurse should observe this client for the development of which breathing pattern as a result of this condition?
- A. Cheyne-Stokes
- B. Biots
- C. Cluster
- D. Kussmauls
Correct Answer: D
Rationale: Metabolic acidosis triggers compensatory hyperventilation to reduce CO2 a process known as Kussmaul respirations (D) characterized by rapid deep breathing. Cheyne-Stokes (A) involves cycles of increasing and decreasing breathing seen in brain injury or heart failure. Biot's (B) features irregular shallow breaths associated with CNS disorders. Cluster (C) breathing involves bursts with pauses linked to brainstem issues. Thus D is correct for metabolic acidosis compensation.