Nokea
The nurse is caring for a client with a tracheostomy. Which of the following actions should the nurse perform to prevent complications?
- A. Suction the tracheostomy every 8 hours.
- B. Clean the inner cannula with sterile technique.
- C. Change the tracheostomy ties daily.
- D. Use a dry gauze dressing around the tracheostomy site.
Correct Answer: B
Rationale: Cleaning the inner cannula with sterile technique prevents infection and ensures airway patency, a priority in tracheostomy care. Suctioning (A) is as needed, not routine, tie changes (C) are less frequent, and dressings (D) should be pre-cut and moisture-resistant.
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A primary belief of psychiatric mental health nursing is:
- A. most people have the potential to change and grow.
- B. every person is worthy of dignity and respect.
- C. human needs are individual to each person.
- D. some behaviors have no meaning and cannot be understood.
Correct Answer: B
Rationale: The belief that every person is worthy of dignity and respect is foundational to psychiatric mental health nursing, emphasizing client-centered care. The other options are also relevant but not the primary belief highlighted here. Psychosocial Integrity
A patient with major depressive disorder is prescribed fluoxetine (Prozac). Which of the following instructions should the nurse include?
- A. Take this medication at bedtime.
- B. Avoid drinking grapefruit juice.
- C. It may take several weeks to feel the full effect.
- D. Stop taking the medication if you feel better.
Correct Answer: C
Rationale: Fluoxetine’s full effect takes 4–6 weeks, and patients must continue it to maintain benefits. Bedtime dosing is not standard, grapefruit juice is irrelevant, and stopping early risks relapse.
Signs of impaired breathing in infants and children include all of the following except:
- A. nasal flaring.
- B. grunting.
- C. seesaw breathing.
- D. quivering lips.
Correct Answer: D
Rationale: Nasal flaring, grunting, and seesaw breathing are signs of respiratory distress in infants and children. Quivering lips are not a recognized indicator of impaired breathing. Physiological Adaptation
John H is a 66-year-old man with a history of heavy smoking presented himself to the ER due to difficulty breathing of 2 years duration. Mr. H was also diagnosed with effusion of the right lung. He is now scheduled for chest tube insertion.
Appropriate patient teaching when the chest tube is removed:
- A. Instruct the patient take deep breath and hold it during removal.
- B. Inform the patient that this is not a painful procedure.
- C. Ensure that the site is covered with a loose, dry dressing.
- D. Expect tachypnea after the removal.
Correct Answer: A
Rationale: Holding a deep breath during removal prevents air entry into the pleural space.
The nurse is caring for a client with a fractured femur who is in skeletal traction. Which of the following actions is MOST important for the nurse to perform?
- A. Check the pin sites for signs of infection.
- B. Ensure the weights are hanging freely.
- C. Perform range-of-motion exercises on the affected leg.
- D. Reposition the client every 4 hours.
Correct Answer: B
Rationale: Ensuring weights hang freely maintains proper traction alignment, preventing complications like malunion. Checking pin sites (A) is important but secondary, ROM exercises (C) are contraindicated in traction, and repositioning (D) is limited to maintain traction.