Nokea
The nurse is changing the ties of the client with a tracheotomy. The safest method of changing the tracheotomy ties is to:
- A. Apply the new tie before removing the old one.
- B. Have a helper present.
- C. Hold the tracheotomy with the nondominant hand while removing the old tie.
- D. Ask the doctor to suture the tracheostomy in place.
Correct Answer: A
Rationale: Applying the new tie before removing the old one ensures the tracheotomy tube remains secure, preventing accidental dislodgement.
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A client has experienced 48 hours of severe repeated bouts of vomiting. Which acid-base imbalance is of most concern?
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct Answer: D
Rationale: Severe vomiting causes loss of gastric acid, leading to metabolic alkalosis (D). Respiratory imbalances (A, B) and metabolic acidosis (C) are less likely.
An AIDS patient has developed a fungal Fusarium infection. The nurse anticipates the physician will order
- A. lamivudine/zidovudine (Combivir).
- B. famciclovir (Famvir).
- C. ciprofloxacin (Cipro).
- D. voriconazole (Vfend)
Correct Answer: D
Rationale: Voriconazole is an antifungal effective against Fusarium. Combivir (antiretroviral), famciclovir (antiviral), and ciprofloxacin (antibacterial) are not appropriate.
A 4-month-old is brought to the well-baby clinic for immunization. In addition to the DPT and polio vaccines, the baby should receive:
- A. Hib titer
- B. Mumps vaccine
- C. Hepatitis B vaccine
- D. MMR
Correct Answer: C
Rationale: At 4 months, the hepatitis B vaccine is part of the standard immunization schedule, along with DPT and polio vaccines.
The nurse is admitting a client with a diagnosis of severe malignant catatonia to the in-patient psychiatric unit. Under which condition would the nurse support the use of electroconvulsive therapy (ECT) as a first-line treatment?
- A. The client is in the first trimester of pregnancy.
- B. The client is gainfully employed.
- C. The client lives in an assisted living facility.
- D. The client is over 50 years of age.
Correct Answer: C
Rationale: ECT may be considered first-line for severe malignant catatonia in a controlled setting like an assisted living facility, where monitoring is feasible. Pregnancy and age are contraindications or require caution, and employment is irrelevant.
The mother calls the clinic to report that her newborn has a rash on his forehead and face. Which action is most appropriate?
- A. Tell the mother to wash the face with soap and apply powder.
- B. Tell her that 30% of newborns have a rash that will go away by one month of life.
- C. Report the rash to the doctor immediately.
- D. Ask the mother if anyone else in the family has had a rash in the last six months.
Correct Answer: B
Rationale: Newborn rashes, such as erythema toxicum, are common and typically resolve spontaneously within weeks, requiring no immediate intervention.