Nokea
The nurse is preparing to suction an adult client with a tracheostomy who has copious amounts of secretions. Which action should the nurse take to accomplish this procedure safely and effectively?
- A. Hyperoxygenate the client after the procedure only.
- B. Apply continuous suction in the airway for up to 20 seconds.
- C. Set the wall suction pressure range between 80 and 120 mm Hg.
- D. Occlude the Y-port of the catheter while advancing it into the tracheostomy.
Correct Answer: C
Rationale: The safe wall suction range for an adult is 80 to 120 mm Hg, making option 3 the action that is consistent with safe and effective practice. The nurse should hyperoxygenate the client both before and after suctioning. The nurse should use intermittent suction in the airway (not constant) for up to 10 to 15 seconds. The nurse should advance the catheter into the tracheostomy without occluding the Y-port to minimize mucosal trauma and aspiration of the client's oxygen.
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A client's medical record states a history of intermittent claudication. In collecting data about this symptom, the nurse should ask the client about which symptom?
- A. Chest pain that is dull and feels like heartburn
- B. Leg pain that is sharp and occurs with exercise
- C. Chest pain that is sudden and occurs with exertion
- D. Leg pain that is achy and gets worse as the day progresses
Correct Answer: B
Rationale: Intermittent claudication is a symptom characterized by a sudden onset of leg pain that occurs with exercise and is relieved by rest. It is the classic symptom of peripheral arterial insufficiency. Chest pain can occur for a variety of reasons, including indigestion or angina pectoris. Venous insufficiency is characterized by an achy type of leg pain that intensifies as the day progresses.
Which of the following conditions is a potential consequence of a prolonged QT interval?
- A. Serious electrolyte imbalance.
- B. Ventricular dysrhythmias.
- C. Heart block.
- D. Atrial dysrhythmias.
Correct Answer: B
Rationale: A prolonged QT interval increases the risk of ventricular dysrhythmias, such as torsades de pointes, which can be life-threatening.
A parent of a 9-year-old child newly diagnosed with diabetes mellitus is very concerned about the child going to school and participating in social events. The nurse creating a plan of care should formulate which goals to address these concerns? Select all that apply.
- A. The child's normal growth and development will be maintained.
- B. The child will use effective coping mechanisms to manage anxiety.
- C. The child and family will discuss all aspects of the illness and its treatments.
- D. The child and family will integrate diabetes care into patterns of daily living.
- E. The child and family will discuss their concerns with the child's teachers and the school nurse.
Correct Answer: D,E
Rationale: To effectively manage social events in the child's life, the family and the child need to integrate the care and management of diabetes into their daily living. In addition, the child's teachers and the school nurse should be aware of their concerns. The other options may be appropriate goals, but they do not deal with social issues.
During you musculoskeletal assessment of the client, you determine that the client has muscular strength against gravity but not against resistance. You would document this assessment as:
- A. 1 on the scale of 1 to 3
- B. 2 on the scale of 1 to 5
- C. 3 on the scale of 0 to 5
- D. 4 on the scale of 0 to 5
Correct Answer: C
Rationale: Muscular strength against gravity but not resistance is graded as 3 on the 0-5 scale, indicating fair strength.
The nurse has conducted a stress management seminar for clients in an ambulatory care setting. Which statement by a client would indicate a need for further teaching?
- A. I can use those guided imagery techniques I've learned anywhere and anytime.
- B. Biofeedback might be nice, but I don't like the idea of having to use equipment.
- C. Using confrontation with coworkers should solve my problems at work quickly.
- D. The progressive muscle relaxation technique should ease my tension headaches.
Correct Answer: C
Rationale: Confrontation is a communication technique, not a stress management technique. It may also exacerbate stress, at least in the short term, rather than alleviate it. Biofeedback, progressive muscle relaxation, meditation, and guided imagery are techniques that the nurse can teach the client to reduce the physical impact of stress on the body and promote a feeling of self-control for the client. Biofeedback entails electronic equipment, whereas the others require no adjuncts, such as tapes, once the technique is learned.