Nokea
The nurse is preparing to suction a tracheostomy for a client with methicillin resistant staphylococcus aureus (MRSA) (see fi gure). The nurse should:
- A. Wear a powered air purifying respirator (PAPR) face shield.
- B. Use goggles that include the hairline.
- C. Change to a surgical mask.
- D. Proceed to suction the client’s tracheostomy.
Correct Answer: D
Rationale: The nurse is wearing protective personnel equipment appropriately for suctioning the client: goggles, gown and respirator mask. It is not necessary to wear a powered air purifying respirator face shield to suction a tracheostomy. A surgical mask does not provide maximum protection.
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The nurse is providing instructions to the parent of a child who had a myringotomy with insertion of tympanostomy tubes. Which instructions should the nurse provide the parent in case the tubes fall out?
- A. Bring the child to the emergency department immediately.
- B. It is not an emergency, but it is best to call the health care clinic.
- C. It is important to replace them immediately so that the surgical opening does not close.
- D. Clean the tubes with half-strength hydrogen peroxide for 30 minutes and then replace them into the child's ears.
Correct Answer: B
Rationale: The parent should be assured that if the tympanostomy tubes fall out, it is not an emergency, but it is best if the primary health care provider or health care clinic is notified. The size and appearance of the tympanostomy tubes should be described to the parent after surgery so that he or she will be familiar with their appearance. The remaining options are incorrect.
A woman is being seen to confirm a possible pregnancy. When the nurse asks the woman how she has been feeling, which statement reflects the expected signs of pregnancy? Select all that apply.
- A. I have been so nauseous.
- B. I am having so much trouble with diarrhea.
- C. I have not had a menstrual period in 2 months.
- D. I have to go to the restroom to urinate all the time.
- E. I have been going to the health club regularly because I have so much energy.
Correct Answer: A,C,D
Rationale: Because the nurse is asking the woman, she would expect presumptive signs of pregnancy to be vocalized. Specifically the presumptive signs of pregnancy are nausea, vomiting, breast changes, amenorrhea, urinary frequency, fatigue, and quickening. Diarrhea is not a typical sign of early pregnancy, and increased energy is less common as fatigue is more typical.
A client has undergone a vaginal hysterectomy. Which interventions should the nurse include in the client's nursing care plan to decrease the risk of deep vein thrombosis or thrombophlebitis? Select all that apply.
- A. Use pneumatic compression boots.
- B. Maintain bed rest for 24 to 48 hours.
- C. Assist with range-of-motion leg exercises.
- D. Elevate the knees with the knee gatch on the bed.
- E. Remove antiembolism stockings twice daily for assessment.
Correct Answer: A,C,E
Rationale: The client is at risk for deep vein thrombosis or thrombophlebitis after this surgery, as for any other major surgery. For this reason, the nurse implements measures that will prevent this complication. Ambulation, pneumatic compression boots, range-of-motion exercises, and antiembolism stockings are all helpful. The nurse should avoid elevating the knees using the knee gatch in the bed, which inhibits venous return and places the client more at risk for deep vein thrombosis or thrombophlebitis.
The nurse is teaching a client with a new diagnosis of celiac disease about dietary management. Which of the following foods should the client avoid?
- A. Rice.
- B. Wheat.
- C. Corn.
- D. Potatoes.
Correct Answer: B
Rationale: Wheat contains gluten, which must be avoided in celiac disease.
The nurse is caring for a client with a history of osteoarthritis. Which of the following non-pharmacologic interventions should be included in the plan of care?
- A. Apply heat to affected joints.
- B. Restrict weight-bearing activities.
- C. Encourage a low-protein diet.
- D. Limit range-of-motion exercises.
Correct Answer: A
Rationale: Heat therapy reduces stiffness and pain in osteoarthritis.