Nokea
The nurse is suctioning the tracheostomy of an adult client. The recommended pressure setting is:
- A. 40-60 mm Hg
- B. 60-80 mm Hg
- C. 80-120 mm Hg
- D. 120-140 mm Hg
Correct Answer: C
Rationale: Suction pressure of 80-120 mm Hg is recommended for adult tracheostomy suctioning to effectively remove secretions without causing trauma.
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A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the nurse enters the room to request something for pain. The nurse should
- A. Administer a placebo
- B. Encourage increased fluid intake
- C. Administer the prescribed analgesia
- D. Recommend relaxation exercises for pain control
Correct Answer: C
Rationale: Administer the prescribed analgesia. Pain relief is a priority in sickle cell crisis, and prescribed analgesics are appropriate.
The nurse is caring for a hospitalized adult who is receiving a blood transfusion. Twenty minutes after the start of the transfusion, the client complains of feeling cold and is shivering. What is the best first action for the LPN to take?
- A. Put a warm blanket on the client
- B. Take the client's vital signs
- C. Elevate the client's feet
- D. Stop the transfusion
Correct Answer: D
Rationale: Shivering and feeling cold during a transfusion suggest a possible transfusion reaction, requiring immediate cessation of the transfusion to prevent further complications, followed by vital signs and physician notification.
During the initial home visit, a nurse is discussing the care of a client newly diagnosed with Alzheimer's disease with family members. Which of these interventions would be most helpful at this time?
- A. leave a book about relaxation techniques
- B. write out a daily exercise routine for them to assist the client to do
- C. list actions to improve the client's daily nutritional intake
- D. suggest communication strategies
Correct Answer: D
Rationale: Alzheimer's disease, a progressive chronic illness, greatly challenges caregivers. The nurse can be of greatest assistance in helping the family to use communication strategies to enhance their ability to relate to the client.
A 14-year old with leukemia tells the nurse, 'All I really want to eat is frozen yogurt.' The nurse should:
- A. Explain the importance of eating a balanced diet
- B. Ask the dietician to talk with the client to find out which foods he prefers
- C. Ask the kitchen to send the yogurt
- D. Document the client's refusal to eat the diet as ordered
Correct Answer: C
Rationale: Providing the requested yogurt respects the client's preferences and encourages intake, which is critical in leukemia patients who may have reduced appetite.
When caring for a client with hypocalcaemia, the nurse should assess for:
- A. A decreased level of consciousness
- B. Tetany
- C. Bradycardia
- D. Respiratory depression
Correct Answer: B
Rationale: Hypocalcemia can cause tetany (muscle spasms or twitching) due to increased neuromuscular excitability.