Nokea
The nurse is preparing to do tracheostomy care on a client. Which tracheostomy care items should the nurse obtain to perform this procedure?
- A. Suction kit and tracheostomy dressing
- B. Bottle of sterile saline and a tracheostomy care kit
- C. Bottles of sterile saline and water and a tracheostomy dressing
- D. Tracheostomy care kit, sterile saline and water, and a suction kit
Correct Answer: D
Rationale: Equipment needed to perform tracheostomy care includes a tracheostomy care kit, sterile water and saline solutions for cleansing and rinsing, and a suction kit for client suctioning. As part of tracheostomy care, the client's airway should be suctioned before cleansing the tracheostomy. New sterile solutions are obtained once per 24 hours, which is often done at the beginning of the workday. A tracheostomy care kit contains the needed supplies for cleaning the tracheostomy and for changing the dressing and holder (trach ties).
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A client being treated for a comminuted fractured tibia asks the nurse to explain what a comminuted fracture means. The nurse should give which response?
- A. It means the fracture is incomplete.
- B. It means the bone is partially fractured.
- C. It means the bone fractured with splintering of the bone into fragments.
- D. It means the skin or mucous membrane was broken when the fracture occurred.
Correct Answer: C
Rationale: A comminuted fracture is a complete fracture across the shaft of a bone, with splintering of the bone into fragments. A simple fracture is a fracture of the bone across its entire shaft with some possible displacement but without breaking the skin. A greenstick fracture is an incomplete fracture, which occurs through part of the cross section of a bone. One side of the bone is fractured, and the other side is bent. A compound fracture, also called an open fracture, is one in which the skin or mucous membrane has been broken, and the wound extends to the depth of the fractured bone.
Which is most closely aligned with ethics?
- A. Morals
- B. Laws
- C. Statutes
- D. Client rights
Correct Answer: A
Rationale: Ethics is most closely aligned with morals , as both involve principles of right and wrong that guide behavior, whereas laws and statutes are legal frameworks, and client rights are specific entitlements.
The nurse assesses for euphoria in a client with multiple sclerosis, looking for which of the following characteristic clinical manifestations?
- A. Inappropriate laughter.
- B. An exaggerated sense of well-being.
- C. Slurring of words when excited.
- D. Visual hallucinations.
Correct Answer: B
Rationale: Euphoria in multiple sclerosis is characterized by an exaggerated sense of well-being, often disproportionate to the client's condition.
The nurse judges that the parent of a 9-month-old infant in a hip spica cast understands how to feed the child when the parent states which of the following?
- A. I can lay my child flat and feed that way.'
- B. I'll raise my child's head up and leave the hips and legs on a pillow.'
- C. I can borrow a special feeding table to use.'
- D. It will take two of us, one to hold and one to feed.'
Correct Answer: B
Rationale: Raising the infant's head while keeping the hips and legs supported minimizes the risk of aspiration and accommodates the hip spica cast's restrictions. Laying flat increases aspiration risk, and the other options are impractical or unnecessary.
The nurse is assessing a client with a suspected stroke. Which of the following findings is most indicative of a stroke?
- A. Sudden unilateral weakness.
- B. Gradual onset of headache.
- C. Bilateral leg pain.
- D. Chronic fatigue.
Correct Answer: A
Rationale: Sudden unilateral weakness is a classic sign of stroke due to impaired blood flow to one side of the brain.