Nokea
The nurse is reviewing discharge teaching with the parent of a pediatric client who has a new tracheostomy. Which of the following statements by the parent would indicate a correct understanding of the teaching?
- A. I will immediately change the tracheostomy tube if my child has difficulty breathing
- B. I will provide deep suctioning frequently to prevent any airway obstruction.
- C. I will remove the humidifier if my child develops more secretions.
- D. I will travel with two tracheostomy tubes, one of the same size and one a size smaller.
Correct Answer: D
Rationale: Carrying two tracheostomy tubes (same and smaller size) is correct for emergency preparedness. Immediate tube changes, frequent deep suctioning, or removing humidifiers can worsen the situation or are unsafe.
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The nurse at the radiological imaging center is admitting a client for an MRI of the right knee. Which information obtained by the nurse should be reported immediately to the prescribing health care provider?
- A. The client ate a full breakfast that morning
- B. The client has an implantable cardiovascular defibrillator (ICD)
- C. The client is allergic to povidone-iodine
- D. The client took all prescribed cardiac medications before arriving
Correct Answer: B
Rationale: An ICD is a contraindication for MRI due to magnetic interference, requiring immediate reporting. Other findings are less critical.
A client who is diagnosed with breast cancer asks the nurse, 'Am I going to die?' Which statement by the nurse promotes a therapeutic relationship?
- A. Cancer is no longer a death sentence; you may live for many years.
- B. I will ask the chaplain to come and talk to you sometime today.
- C. Many people with cancer experience fear of dying; tell me about your concerns.
- D. Tell me about your life. What are your hopes and goals for the future?
Correct Answer: C
Rationale: This response validates the client's fear and invites further discussion, fostering trust and a therapeutic relationship. A offers reassurance but may dismiss the client's emotions. B deflects to another provider without addressing the concern. D shifts focus away from the client's immediate fear, missing the opportunity to explore their feelings.
The nurse finds a client on the floor in the client's room. Based on the documentation shown in the exhibit, the nurse made an incorrect entry in the client's medical record at what time?
- A. 1700
- B. 1710
- C. 1740
- D. 1810
Correct Answer: C
Rationale: Without specific exhibit details, 1740 is assumed incorrect based on context, possibly due to a documentation error related to the fall. Rationale is limited without exhibit.
The charge nurse on the eating disorder unit instructs a new staff member to weigh each client in his or her hospital gown only. What is the rationale for this nursing intervention?
- A. To reduce the risk of the client feeling cold due to decreased fat and subcutaneous tissue
- B. To cover the bony prominence and areas where there is skin breakdown
- C. The client knows what type of clothing to wear when weighed
- D. To reduce the tendency of the client to hide objects under his or her clothing
Correct Answer: D
Rationale: To reduce the tendency of the client to hide objects under his or her clothing. Clients may conceal weights to falsely indicate weight gain.
The nurse is talking with the parent of a 6-year-old client about how to share details of the client's adoption. Which of the following thought processes would be consistent with the expected cognitive development of the client?
- A. feels responsible for being placed for adoption
- B. imagines what life would be like with the biological family
- C. worries about what peers will say or think about being adopted
- D. defies adoptive parents and asks for information about birth parents
Correct Answer: B
Rationale: At age 6, children can imagine scenarios like life with biological parents, consistent with concrete operational thinking. Other options reflect older or atypical development.