Nokea
The nurse is observing a staff member perform open suctioning for a client who has a tracheostomy tube. The nurse should intervene if the staff member is observed
- A. flushing the suction catheter with 0.9% sodium chloride after each suction pass
- B. placing the client in the semi-Fowler position prior to suctioning
- C. applying intermittent suction while inserting the suction catheter
Correct Answer: C
Rationale: Applying suction while inserting the catheter can cause tracheal mucosa damage and hypoxia. Flushing the catheter with saline maintains patency, and semi-Fowler position aids breathing and reduces aspiration risk during suctioning.
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The most common cause of injury from a house fire is:
- A. explosion.
- B. falls from second-story windows.
- C. thermal damage to skin and body surfaces.
- D. inhalation injury.
Correct Answer: D
Rationale: Inhalation injury, from smoke and toxic gases, is the most common cause of house fire injuries, often leading to respiratory compromise. Thermal damage is also significant but less frequent. Accident Prevention
A nurse is documenting notes in the client's electronic record after making rounds on assigned clients. Which entry is an appropriate documentation?
- A. Client appears to be sleeping. Eyes closed
- B. Client reports, 'I'm in pain.' Medication provided
- C. Inspiratory wheezes heard in bilateral lower lung fields
- D. Voided x1
Correct Answer: C
Rationale: Inspiratory wheezes in bilateral lower lung fields is a specific, objective finding that accurately describes the client's condition. The other entries are vague, lack detail, or are subjective without supporting data.
The nurse in the emergency department is caring for a client who is experiencing an acute exacerbation of asthma. Which of the following medications should the nurse expect to administer?
- A. Nebulized albuterol
- B. PO montelukast sodium
- C. IV methylprednisolone succinate
- D. Inhaled ipratropium
- E. Inhaled salmeterol
Correct Answer: A
Rationale: Nebulized albuterol, a short-acting beta-agonist, rapidly relieves bronchospasm in acute asthma exacerbations. Montelukast is for maintenance, methylprednisolone is slower-acting, ipratropium is secondary, and salmeterol is long-acting, not for acute relief.
Which comment by the client is most significant in light of the fact that he has Ménière's disease?
- A. I take a walk every day.
- B. I listen to my iPOD a lot.
- C. I smoke a pack of cigarettes a day.
- D. It is very noisy at my workplace.
Correct Answer: C
Rationale: Cigarette smoking has been shown to aggravate Ménière's disease. The client will be told to stop smoking to decrease the frequency and severity of Ménière's. Walking, listening to an IPOD or other electronic device, and exposure to noise have not been shown to be related to Ménière's disease.
A 5-year old with a suspected ventricular septal defect is scheduled for a cardiac catheterization. The child's mother asks the nurse, 'Why does my little girl have to have that tube put into her heart?' The nurse should tell the mother that the cardiac catheterization will:
- A. Identify how much her heart is enlarged
- B. Show the size and exact location of the defect
- C. Show whether the ventricles are enlarged
- D. Determine the existence of a murmur
Correct Answer: B
Rationale: Cardiac catheterization visualizes the heart's structures, allowing precise identification of the size and location of a ventricular septal defect.