Nokea
The nurse is caring for a client with a tracheostomy who requires suctioning. Which of the following actions by the nurse would indicate correct technique?
- A. Using a size 16 Fr catheter to suction the client.
- B. Withdrawing the suction catheter 1 to 2 cm before applying suction.
- C. Using 160 mm Hg of pressure when suctioning the client.
- D. Applying suction to the catheter for 25 seconds during withdrawal.
Correct Answer: B
Rationale: Withdrawing the catheter 1-2 cm before suctioning prevents mucosal trauma. A 16 Fr catheter may be too large, 160 mm Hg is excessive (80-120 mm Hg is typical), and suctioning for 25 seconds is too long (≤10-15 seconds).
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The nurse is admitting a client diagnosed with hepatitis B. The nurse would be able to cohort the client in the same room with which of the following clients? A client with
- A. Heart failure receiving diuretics
- B. Bacterial meningitis receiving antibiotics
- C. Prostate cancer receiving brachytherapy
- D. Varicella prescribed antivirals
Correct Answer: A
Rationale: Hepatitis B is transmitted via blood/body fluids, so rooming with a heart failure client is safe. Meningitis, varicella, and brachytherapy require specific precautions or isolation.
The nurse is helping the unlicensed assistive personnel pass meal trays. When providing a meal tray for a client diagnosed with pheochromocytoma, which dietary item should the nurse remove?
- A. Macaroni and cheddar cheese
- B. Watermelon slices
- C. Caffeine free cola
- D. Baked chicken
Correct Answer: C
Rationale: Pheochromocytoma requires avoiding stimulants like caffeine, even in decaffeinated cola, which may contain trace amounts. Other items are safe.
Which of the following responses should the nurse avoid when communicating with a client who has just received a poor prognosis? Select all that apply.
- A. My mother has the same thing.
- B. I'll sit with you for a while.
- C. I think you should try having surgery.
- D. Don't cry, everything is going to be okay.
- E. Do you have any questions for me right now?
Correct Answer: A,C,D
Rationale: Avoid personal anecdotes, medical advice, or minimizing emotions, as they dismiss the client’s feelings. Offering presence and open-ended questions are therapeutic.
The infection control nurse is conducting rounds on the nursing unit and should ensure which conditions are isolated with droplet precautions? Select all that apply.
- A. Clostridium difficile
- B. Cryptococcal meningitis
- C. Mycoplasma pneumonia
- D. Haemophilus influenzae, type b pneumonia
- E. Rheumatic fever
- F. Varicella Zoster
- G. Scabies
Correct Answer: C,D
Rationale: Mycoplasma pneumonia and Haemophilus influenzae pneumonia require droplet precautions. Others require contact or standard precautions.
The nurse is caring for an older adult following a total hip arthroplasty. The nurse should anticipate a prescription for which postoperative medication?
- A. Hydrocortisone
- B. Enoxaparin
- C. Metoprolol
- D. Furosemide
- E. Morphine
Correct Answer: B,E
Rationale: Enoxaparin prevents venous thromboembolism, a common risk post-hip arthroplasty, and morphine manages postoperative pain. Hydrocortisone, metoprolol, and furosemide are not routinely prescribed unless indicated by specific conditions.