Nokea
The nurse is caring for a client with a tracheostomy. Which action is a priority during tracheostomy care?
- A. Clean the inner cannula with sterile technique.
- B. Apply a dry dressing to the tracheostomy site.
- C. Suction the tracheostomy after cleaning.
- D. Change the tracheostomy ties daily.
Correct Answer: A
Rationale: Cleaning the inner cannula with sterile technique prevents infection and maintains airway patency, a priority. Dressings (B), suctioning (C), and tie changes (D) are secondary.
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A female client presents to the obstetric-gynecology clinic for a pregnancy test, the result which turns out to be positive. Her last menstrual period began December 10, 1993. Using Nägele's rule, the nurse estimates her date of delivery to be:
- A. 17-Sep-94
- B. 10-Sep-94
- C. 3-Sep-94
- D. 17-Aug-94
Correct Answer: A
Rationale: According to Nägele's rule, the estimated date of delivery is calculated by adding 7 days to the date of the first day of the normal menstrual period (December 10 + 7 days = December 17), and then by counting back 3 months (December 17 - 3 mo = September 17). (B, C, D) These answers are incorrect.
A client with a renal failure is prescribed a low potassium diet. Which food choice would be best for this client?
- A. 1 cup beef broth
- B. 1 baked potato with the skin
- C. 1/2 cup raisins
- D. 1 cup rice
Correct Answer: D
Rationale: A low potassium diet is essential for clients with renal failure to prevent hyperkalemia. Among the options, 1 cup of rice has the lowest potassium content (approximately 50–100 mg per cup), making it the best choice. Beef broth contains moderate potassium (around 200 mg per cup), a baked potato with skin is high in potassium (about 900 mg), and raisins are also high (around 500 mg per half cup).
A client's transfusion of packed red blood cells has been infusing for 2 hours. She is complaining of a raised, itchy rash and shortness of breath. She is wheezing, anxious, and very restless. The nurse knows these assessment findings are congruent with:
- A. Hemolytic transfusion reaction
- B. Febrile transfusion reaction
- C. Circulatory overload
- D. Allergic transfusion reaction
Correct Answer: D
Rationale: A hemolytic transfusion reaction would be characterized by fever, chills, chest pain, hypotension, and tachypnea. Fever, chills, and headaches are indicative of a febrile transfusion reaction. Circulatory overload is manifest by dyspnea, cough, and pulmonary crackles. Urticaria, pruritus, wheezing, and anxiety are indicative of an allergic transfusion reaction.
The mother of a one-year-old with sickle cell anemia wants to know why the condition didn't show up in the nursery. The nurse's response is based on the knowledge that:
- A. There is no test to measure abnormal hemoglobin in newborns.
- B. Infants do not have insensible fluid loss before a year of age.
- C. Infants rarely have infections that would cause them to have a sickling crises.
- D. The presence of fetal hemoglobin protects the infant.
Correct Answer: D
Rationale: Fetal hemoglobin (HbF), predominant in newborns, inhibits sickling in sickle cell anemia, delaying symptoms until HbF decreases around 6 months. Newborn screening exists, and infections can trigger crises later.
The nurse is caring for the client who has been in a coma for two months. He has signed a donor card, but the wife is opposed to the idea of organ donation. How should the nurse handle the topic of organ donation with the wife?
- A. Tell the wife that the hospital will honor her wishes regarding organ donation, but contact the organ-retrieval staff.
- B. Tell her that because her husband signed a donor card, the hospital has the right to take the organs upon the death of her husband.
- C. Explain that it is necessary for her to donate her husband's organs because he signed the permit.
- D. Refrain from talking about the subject until after the death of her husband.
Correct Answer: D
Rationale: Discussing organ donation with the wife while the client is still alive may cause distress, especially given her opposition. The nurse should refrain from raising the topic until after the client’s death, respecting her emotional state and hospital policy, which typically involves organ donation teams post-mortem.