Nokea
The nurse is caring for a client with a tracheostomy. Which of the following actions is the highest priority to maintain airway patency?
- A. Suctioning the tracheostomy as needed.
- B. Cleaning the tracheostomy site daily.
- C. Humidifying the inspired air.
- D. Securing the tracheostomy tube.
Correct Answer: A
Rationale: Suctioning as needed is the highest priority to maintain airway patency by removing mucus or obstructions from the tracheostomy.
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A client with a history of multiple sclerosis is admitted with muscle weakness. The nurse should include which of the following in the plan of care?
- A. Assist with activities of daily living.
- B. Restrict physical activity.
- C. Provide a high-carbohydrate diet.
- D. Limit fluid intake.
Correct Answer: A
Rationale: Assisting with activities of daily living supports safety and independence in multiple sclerosis.
A Jewish client requests an orthodox diet while she is hospitalized. The nurse should refer this request to the:
- A. Dietitian
- B. Physician
- C. Unit case manager
- D. Rabbi in pastoral care
Correct Answer: A
Rationale: The dietitian is responsible for addressing dietary requests, including religious preferences like an orthodox Jewish diet, to ensure nutritional needs are met. The physician, case manager, or rabbi may not specialize in dietary planning.
The nurse reviewing the electrocardiogram (ECG) rhythm strip of a client with a history of a myocardial infarction (MI) notes that the PR intervals are 0.16 seconds. The nurse should arrive at which interpretation of this assessment data?
- A. A normal finding
- B. An abnormal finding
- C. An impending reinfarction
- D. First-degree atrioventricular (AV) block
Correct Answer: A
Rationale: The PR interval represents the time it takes for the cardiac impulse to spread from the atria to the ventricles. The PR interval range is 0.12 to 0.2 seconds. Therefore, the finding is normal. The remaining options all indicate an abnormal finding, so they are not appropriate responses.
A client with a diagnosis of chronic heart failure is prescribed digoxin (Lanoxin). The nurse should monitor the client for which of the following signs of toxicity?
- A. Tachycardia.
- B. Yellow vision.
- C. Weight gain.
- D. Dry cough.
Correct Answer: B
Rationale: Yellow vision is a classic sign of digoxin toxicity, indicating the need for immediate evaluation.
The nurse observes a client during a seizure and notes that the client's entire body became rigid, and the muscles in all four extremities alternated between relaxation and contraction. Which type of seizure should the nurse document that the client had experienced?
- A. Partial seizure
- B. Absence seizure
- C. Tonic-clonic seizure
- D. Complex partial seizure
Correct Answer: C
Rationale: The description of the seizure, with the entire body becoming rigid (tonic phase) followed by alternating relaxation and contraction of muscles in all four extremities (clonic phase), is characteristic of a tonic-clonic seizure. Partial seizures involve only a portion of the body or brain, absence seizures are brief lapses in awareness without significant motor activity, and complex partial seizures involve altered consciousness with automatisms, none of which match the described symptoms.