Nokea
The nurse is caring for a client with a tracheostomy tube in place. During tracheostomy care, the nurse accidentally dislodges the tube. Which of the following actions should the nurse take FIRST?
- A. Insert a new tracheostomy tube immediately.
- B. Call for assistance from the respiratory therapist.
- C. Attempt to reinsert the dislodged tube.
- D. Cover the stoma with a sterile dressing.
Correct Answer: A
Rationale: immediate reinsertion of a tracheostomy tube is critical to maintain airway patency
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A young adult patient constantly seeks attention from the nurses, stomping away from the nurses’ station and pouting when her requests are refused. Which of the following responses by the nurse is MOST appropriate?
- A. Have the patient establish trust with one staff person with whom therapeutic interventions should occur.
- B. Give the patient unsolicited attention when she is not exhibiting the unacceptable behaviors.
- C. Ignore the patient when she exhibits attention-seeking behavior.
- D. Rotate the staff so the patient will learn to relate to more than one nurse.
Correct Answer: B
Rationale: reward nonseeking attention behaviors by giving the patient unsolicited attention
A client with pregnancy-induced hypertension is scheduled for a C-section. Before surgery, the nurse should keep the client:
- A. On her right side
- B. Supine with a small pillow
- C. On her left side
- D. In knee chest position
Correct Answer: C
Rationale: The left lateral position improves uterine perfusion and reduces pressure on the vena cava in clients with pregnancy-induced hypertension.
The doctor has prescribed Exelon (rivastigmine) for the client with Alzheimer's disease. Which side effect is most often associated with this drug?
- A. Urinary incontinence
- B. Headaches
- C. Confusion
- D. Nausea
Correct Answer: D
Rationale: Nausea is the most common side effect of rivastigmine, a cholinesterase inhibitor used for Alzheimer's disease.
A client with advanced Alzheimer's disease has been prescribed haloperidol (Haldol). What clinical manifestation suggests that the client is experiencing side effects from this medication?
- A. Cough
- B. Tremors
- C. Diarrhea
- D. Pitting edema
Correct Answer: B
Rationale: Haloperidol, an antipsychotic, can cause extrapyramidal side effects like tremors, which are common and indicate a neurological side effect.
An elderly client with an abdominal surgery is admitted to the unit following surgery. In anticipation of complications of anesthesia and narcotic administration, the nurse should:
- A. Administer oxygen via nasal cannula
- B. Have narcan (naloxane) available
- C. Prepare to administer blood products
- D. Prepare to do cardioresuscitation
Correct Answer: B
Rationale: Narcan reverses opioid overdose, a potential complication of narcotic use post-surgery.