Nokea
The nurse is performing routine tracheostomy care. Which of the following steps would be appropriate for the nurse to include in the performance of the procedure?
- A. Remove the inner cannula every 2 hours for cleaning.
- B. Secure the tracheostomy ties with a square knot.
- C. Use cut gauze under the neck plate to protect the skin.
- D. Suction the inner cannula on completion of the procedure.
Correct Answer: B
Rationale: Securing tracheostomy ties with a square knot ensures stability and safety. Frequent cannula removal is unnecessary, cut gauze may fray, and suctioning is done as needed, not routinely.
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A client with a history of peptic ulcer disease is prescribed ranitidine (Zantac). The nurse should explain that this medication works by:
- A. Neutralizing gastric acid.
- B. Reducing gastric acid secretion.
- C. Coating the stomach lining.
- D. Increasing gastric motility.
Correct Answer: B
Rationale: Ranitidine, an H2-receptor blocker, reduces gastric acid secretion, helping to heal peptic ulcers.
A client with a history of rheumatoid arthritis is prescribed methotrexate. The nurse should monitor the client for which of the following adverse effects?
- A. Hepatotoxicity.
- B. Hyperkalemia.
- C. Hypotension.
- D. Weight gain.
Correct Answer: A
Rationale: Methotrexate can cause hepatotoxicity, requiring regular liver function tests.
The nurse is developing a community health education program about sexually transmitted diseases. Which information about women who acquire gonorrhea should be included?
- A. Women are more reluctant than men to seek medical treatment.
- B. Gonorrhea is not easily transmitted to women who are menopausal.
- C. Women with gonorrhea are usually asymptomatic.
- D. Gonorrhea is usually a mild disease for women.
Correct Answer: C
Rationale: Women with gonorrhea are often asymptomatic, which increases the risk of delayed treatment and complications, a key point for education.
The antidote for heparin is:
- A. Vitamin K.
- B. Warfarin (Coumadin).
- C. Thrombin.
- D. Protamine sulfate.
Correct Answer: D
Rationale: Protamine sulfate rapidly reverses heparin's anticoagulant effects by binding to it, neutralizing its activity.
A client with a history of peptic ulcer disease is admitted to the hospital. Initial assessment reveals that his blood pressure is 96/60 mm Hg, his pulse rate is 120 bpm, and he has vomited coffee-ground material. Based on this assessment, what is the nurse's priority action?
- A. Administer an antiemetic.
- B. Prepare to insert a nasogastric (NG) tube.
- C. Collect data regarding recent client stressors.
- D. Place the client in a modified Trendelenburg position.
Correct Answer: D
Rationale: The symptoms suggest gastrointestinal bleeding, and the modified Trendelenburg position helps maintain cerebral perfusion in hypovolemic shock.