Nokea
The nurse is caring for a client with an endotracheal tube attached to a ventilator. The high-pressure alarm sounds on the ventilator. The nurse prepares to perform which priority nursing intervention?
- A. Suction the client.
- B. Check for a disconnection.
- C. Notify the respiratory therapist.
- D. Evaluate the tube cuff for a leak.
Correct Answer: A
Rationale: A high-pressure alarm on a ventilator indicates obstruction or resistance, often from secretions; suctioning (A) is the priority to clear the airway. Checking for disconnection (B) fits low-pressure alarms. Notifying respiratory therapy (C) delays action. Evaluating the cuff (D) addresses leaks, not high pressure. A is correct. Rationale: Suctioning resolves common causes like mucus plugs, restoring ventilation swiftly, a first-line action per ventilator management protocols, critical to prevent hypoxia or barotrauma.
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An autoclave is used to sterilize hospital supplies because:
- A. More articles can be sterilized at a time
- B. Steam causes less damage to the materials
- C. A lower temperature can be obtained
- D. Pressurized steam penetrates the supplies better
Correct Answer: D
Rationale: Pressurized steam enhances penetration, ensuring thorough sterilization.
According to Maslow, which of the following is TRUE about a self actualized person?
- A. Makes decision contrary to public opinion
- B. Do not predict events
- C. Self centered
- D. Maximum degree of self conflict
Correct Answer: A
Rationale: Maslow's self-actualized individual (1940s) decides independently e.g., rejecting trends for ethics. They predict events (insight), aren't self-centered (altruistic), and minimize conflict. Nurses foster this e.g., supporting unconventional choices enhancing self-directed health decisions, per humanistic theory.
A client with a new diagnosis of type 1 diabetes mellitus is being taught by a nurse. Which of the following statements should the nurse include in the teaching?
- A. You can still eat sugar, but you must count it in your carbohydrate count for the day.
- B. You need to avoid all forms of sugar to keep your blood glucose levels under control.
- C. You can eat unlimited amounts of proteins and fats since they do not affect blood glucose levels.
- D. You will need to take an oral hypoglycemic agent every day to manage your blood glucose levels.
Correct Answer: A
Rationale: The correct statement to include in teaching a client with type 1 diabetes mellitus is that they can still eat sugar, but they must count it in their carbohydrate intake for the day. This is important because clients with type 1 diabetes need to manage their blood glucose levels by calculating their carbohydrate intake, including sugars. Choice B is incorrect because total avoidance of sugar is not necessary, but monitoring and including it in the carbohydrate count is essential. Choice C is incorrect as proteins and fats can also affect blood glucose levels and should be consumed in moderation. Choice D is incorrect since oral hypoglycemic agents are not used in type 1 diabetes mellitus, as insulin replacement therapy is the mainstay of treatment.
Which of the following statement is TRUE about case management?
- A. Focuses on one visit
- B. Coordinates care for complex needs
- C. Only for acute care
- D. All of the above
Correct Answer: B
Rationale: Case management coordinates care for complex needs (B), per model e.g., chronic illness. Not one visit (A), not acute-only (C), not all (D) long-term focus. B truly defines case management's role, making it correct.
A client with chronic kidney disease is being educated by a nurse about dietary management. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should limit my intake of protein to prevent overworking my kidneys.
- B. I should increase my intake of potassium-rich foods.
- C. I should increase my intake of phosphorus-rich foods.
- D. I should increase my intake of calcium-rich foods.
Correct Answer: A
Rationale: The correct answer is A. In chronic kidney disease, limiting protein intake is crucial to prevent overworking the kidneys. Excessive protein consumption can lead to the accumulation of metabolic waste products that the kidneys struggle to process, worsening kidney function. Therefore, by recognizing the need to restrict protein intake, the client demonstrates an understanding of the dietary management required for their condition. Choices B, C, and D are incorrect. Increasing intake of potassium-rich foods (Choice B) is not recommended in chronic kidney disease as it can lead to hyperkalemia. Similarly, increasing intake of phosphorus-rich foods (Choice C) is not advised because impaired kidneys struggle to excrete phosphorus, leading to elevated levels in the blood. Lastly, increasing intake of calcium-rich foods (Choice D) may not be necessary unless there is a specific deficiency or requirement, as calcium balance is often disrupted in chronic kidney disease.