Nokea
The nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which occurs?
- A. Suctioning is required frequently.
- B. Aspiration of gastric contents occurs when suctioning.
- C. The client's skin and mucous membranes are light pink.
- D. Excessive secretions are suctioned from a tracheostomy.
Correct Answer: B
Rationale: Tracheoesophageal fistula (TEF), a rare tracheostomy complication, involves an abnormal connection between trachea and esophagus. Aspiration of gastric contents during suctioning (B) is a definitive sign, indicating esophageal leakage into the airway. Frequent suctioning (A) or excessive secretions (D) are nonspecific. Pink skin (C) reflects good oxygenation, not TEF. B is correct. Rationale: TEF allows gastric contents to enter the trachea, detected during suctioning, requiring urgent intervention like tube adjustment or surgery, distinct from routine secretion issues, per critical care nursing.
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Which of the following statement best describe infection control?
- A. Ignoring hygiene
- B. Preventing disease spread
- C. A patient task
- D. A one-time action
Correct Answer: B
Rationale: Infection control is preventing disease spread (B), per nursing e.g., handwashing. Not ignoring (A), not task (C), not one-time (D) ongoing prevention. B best defines its protective role, like for Mr. Gary, making it correct.
A client has a new diagnosis of lactose intolerance and is receiving teaching from a nurse about dietary management. Which of the following statements should the nurse include in the teaching?
- A. You should avoid foods that contain lactose.
- B. You should increase your intake of high-fiber foods.
- C. You should avoid foods that contain gluten.
- D. You should increase your intake of dairy products.
Correct Answer: A
Rationale: The correct statement for the nurse to include in teaching a client with lactose intolerance is to avoid foods that contain lactose. Lactose intolerance results from the body's inability to digest lactose, a sugar found in dairy products. By avoiding foods containing lactose, the client can manage symptoms and prevent complications associated with lactose intolerance. Choices B, C, and D are incorrect. Increasing intake of high-fiber foods (choice B) may be beneficial for general health but is not directly related to lactose intolerance. Avoiding gluten (choice C) is necessary for individuals with celiac disease, not lactose intolerance. Increasing intake of dairy products (choice D) would worsen symptoms in individuals with lactose intolerance due to the lactose content.
Which of the following situation best describe an ethical dilemma?
- A. The nurse is not sure what time to give the medication
- B. The client refuses a procedure that can save his life
- C. The client asks what his diagnosis is
- D. The nurse forgot to give the medication
Correct Answer: B
Rationale: Client refusing a life-saving procedure (B) is an ethical dilemma autonomy vs. beneficence, per ethics. Timing (A) and forgetting (D) are errors, asking diagnosis (C) routine. B's conflicting principles best exemplify a dilemma, making it correct.
A client has a new diagnosis of osteoarthritis and is being taught about dietary management. Which of the following statements should be included in the teaching?
- A. Increase your intake of calcium-rich foods.
- B. Avoid foods that are high in potassium.
- C. Increase your intake of vitamin D-rich foods.
- D. Avoid foods that are high in sodium.
Correct Answer: C
Rationale: The correct statement to include in the teaching is to increase the intake of vitamin D-rich foods. Vitamin D helps improve calcium absorption, which is beneficial for bone health and may help alleviate symptoms of osteoarthritis. Option A is incorrect because while calcium is important for bone health, the focus should be on vitamin D for calcium absorption. Option B is incorrect as potassium is generally not restricted in osteoarthritis. Option D is also incorrect as sodium restriction is more relevant for conditions like hypertension or heart failure, not specifically for osteoarthritis.
A client with a new diagnosis of hypothyroidism is being taught about medication management. Which of the following statements should the nurse include in the teaching?
- A. You should take your medication with a high-fiber meal.
- B. You should take your medication on an empty stomach.
- C. You should take your medication with a calcium supplement.
- D. You should take your medication before bedtime.
Correct Answer: B
Rationale: The correct answer is B: 'You should take your medication on an empty stomach.' When educating a client with hypothyroidism, it is essential to advise taking thyroid medication on an empty stomach to enhance absorption and effectiveness. Taking the medication with food, especially high-fiber or with supplements like calcium, can interfere with absorption and reduce its efficacy. Therefore, it is crucial for the client to follow the recommendation of taking the medication on an empty stomach. Choices A, C, and D are incorrect because taking the medication with a high-fiber meal (Choice A) or with a calcium supplement (Choice C) can hinder absorption, and taking it before bedtime (Choice D) does not optimize absorption compared to taking it on an empty stomach.