Nokea
The nurse is preparing to suction a client who has a tracheostomy tube. Which of the following actions should the nurse take? Select all that apply.
- A. Administer 100% oxygen prior to suctioning the client
- B. Limit suctioning to 20 seconds during each suction pass
- C. Use sterile gloves and technique throughout the procedure
- D. Instill sterile normal saline into the tracheostomy tube prior to suctioning
- E. Apply suction while withdrawing the catheter from the tracheostomy tube
Correct Answer: A,C,E
Rationale: Pre-oxygenation, sterile technique, and suction on withdrawal prevent hypoxia and infection. Suctioning should be limited to 10-15 seconds, and saline instillation is not routinely recommended.
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A client asks, 'What should I do to prepare for a colonoscopy?' Which instructions should the nurse reinforce to correctly answer the client’s question? Select all that apply.
- A. No food or drink is allowed 8 hours prior to the test
- B. Prophylactic antibiotics are taken as prescribed
- C. Smoking must be avoided after midnight
- D. The day prior to the procedure your diet will be clear liquids
- E. You will drink polyethylene glycol as directed the day before
Correct Answer: A,D,E
Rationale: Fasting 8 hours, clear liquids the day before, and polyethylene glycol are standard colonoscopy preparations. Antibiotics are not routine, and smoking cessation is not specific to the procedure.
Exhibit 1
Medication administration record
Allergies: No known drug allergies
Medication Time
Insulin NPH: 75 units subcutaneously, twice daily 0800, 2000
Insulin lispro: sliding scale dosing, before meals and at bedtime 0800, 1130, 1730, 2100
Exhibit 2
Laboratory results and reference ranges
Sodium
136-145 mEq/L
(136-145 mmol/L) 141 mEq/L
(141 mmol/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L) 3.0 mEq/L
(3.0 mmol/L)
Glucose (fasting)
70-110 mg/dL
(3.9-6.1 mmol/L) 328 mg/dL
(18.2 mmol/L)
The nurse is preparing to administer medications scheduled for 0800 to a client with type 1 diabetes mellitus. After reviewing the client's morning laboratory test results, which of the following actions would be a priority for the nurse to take?
- A. Administer insulin lispro per protocol and insulin NPH
- B. Contact the client's health care provider
- C. Obtain a urine specimen to check for ketones
- D. Recheck the client's capillary blood glucose level
Correct Answer: B
Rationale: Abnormal lab results (e.g., severe hypo/hyperglycemia) require provider notification to adjust treatment. Administering insulin, checking ketones, or rechecking glucose are secondary without specific lab values.
After receiving shift report, the nurse is assessing a client started on trimethoprim-sulfamethoxazole 2 days ago for treatment of a urinary tract infection. The client reports itching, and the nurse notices a diffuse maculopapular rash on the client's face. What should the nurse do first?
- A. Administer diphenhydramine
- B. Administer injectable epinephrine
- C. Examine the client's trunk and limbs
- D. Reassess the client's allergy history
Correct Answer: C
Rationale: Examining the trunk and limbs determines the rash’s extent, guiding whether it’s a mild reaction or a severe one (e.g., Stevens-Johnson syndrome). Diphenhydramine, epinephrine, or allergy reassessment are secondary until the rash is fully assessed.
While reviewing the chart of an elderly client, the nurse notes that the last recorded temperature for the preceding shift was 104°. There is no documented intervention. The nurse should:
- A. Check the doctor's orders for an antipyretic.
- B. Ask the client whether he has received any medication for his fever.
- C. Call the nurse at home to validate whether the medication was given.
- D. Retake the client's temperature.
Correct Answer: D
Rationale: Retaking the temperature verifies the current status, as the fever may have resolved. Checking orders or asking the client assumes the fever persists, and calling the nurse is impractical.
An adult asks the nurse what could be causing him to have a black tongue and black stools. The following items are in the client's history. Which is most likely to be causing his symptoms?
- A. He is taking bismuth subsalicylate (Pepto-Bismol) for loose stools.
- B. He has been eating a lot of beets and broccoli recently.
- C. He has been taking iron tablets for anemia.
- D. He eats a lot of red meat.
Correct Answer: A
Rationale: Bismuth subsalicylate commonly causes black tongue and stools, a harmless side effect, unlike the other options.