Nokea
The nurse is preparing to suction a client with a new tracheostomy in the postanesthesia recovery room. Which of the following actions, if performed by the nurse, indicates a break in proper technique?
- A. The nurse sets the suction source at 120 mm Hg and obtains a #14 French suction catheter.
- B. The nurse inserts the suction catheter until resistance is met, and then applies intermittent suction as the catheter is withdrawn.
- C. The nurse suctions the client's mouth prior to suctioning the tracheostomy to ensure a patent airway.
- D. The nurse administers oxygen to the client using an Ambu bag attached to 100% oxygen prior to suctioning.
Correct Answer: C
Rationale: break in sterile procedure, suction mouth after trachea
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A client is admitted for treatment of severe anxiety. It is MOST important for the nurse to obtain which of following information during the first 48 hours after admission?
- A. What is important to the client.
- B. How the client views herself.
- C. In what situations the client gets anxious.
- D. If anyone in the client's family has had mental problems.
Correct Answer: C
Rationale: will provide necessary information in baseline assessment of client's anxiety
When assessing orientation to person, place, and time for an elderly hospitalized client, which of the following principles should be understood by the nurse?
- A. Short-term memory is more efficient than long-term memory.
- B. The stress of an unfamiliar environment may cause confusion.
- C. A decline in mental status is a normal part of aging.
- D. Learning ability is reduced during hospitalization of the elderly client.
Correct Answer: B
Rationale: stress of an unfamiliar situation or environment may lead to confusion in elderly clients
A client is receiving a blood transfusion. Fifteen minutes after the transfusion begins, the client develops a fever and chills. Which of the following actions should the nurse take FIRST?
- A. Stop the transfusion immediately.
- B. Notify the physician.
- C. Administer acetaminophen.
- D. Increase the infusion rate.
Correct Answer: A
Rationale: fever and chills may indicate a transfusion reaction, and the transfusion must be stopped immediately
The daughter of a 70-year-old patient with cancer asks the nurse, 'Do you believe in euthanasia?' Which of the following responses by the nurse is BEST?
- A. I think that each person has to decide this issue for herself.
- B. My religion is opposed to euthanasia.
- C. What are your thoughts about euthanasia?
- D. Did you see the TV program about euthanasia last night?
Correct Answer: C
Rationale: open-ended question, allows client to verbalize
The nurse is teaching a client about warfarin (Coumadin) therapy. Which of the following statements by the client indicates a need for further teaching?
- A. I will avoid contact sports while taking this medication.
- B. I will check with my doctor before taking any new medications.
- C. I will increase my intake of green leafy vegetables.
- D. I will report any unusual bleeding to my doctor.
Correct Answer: C
Rationale: green leafy vegetables are high in vitamin K, which can decrease the effectiveness of warfarin