Nokea
The nurse is suctioning the tracheostomy of an adult client. The recommended pressure setting for performing tracheostomy suctioning on the adult client is:
- A. 40-60 mmHg
- B. 60-80 mmHg
- C. 80-120 mmHg
- D. 120-140 mmHg
Correct Answer: C
Rationale: Recommended suction pressure for adult tracheostomy is 80-120 mmHg to effectively remove secretions without causing trauma. Higher or lower pressures are less safe or effective.
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A client with cystic fibrosis exhibits activity intolerance related to the pulmonary problems associated with his disease. However, he needs to be encouraged to participate in daily physical exercise. The ultimate aim of exercise is to:
- A. Create a sense of well-being and self-worth
- B. Help him overcome respiratory infections
- C. Establish an effective, habitual breathing pattern
- D. Promote normal growth and development
Correct Answer: C
Rationale: Physical exercise is an important adjunct to chest physiotherapy. It stimulates mucus secretion, promotes a feeling of well-being, and helps to establish a habitual breathing pattern.
The client is admitted with a diagnosis of preterm labor. Which symptom is most characteristic?
- A. Uterine contractions
- B. Fetal macrosomia
- C. Maternal fever
- D. Painless vaginal bleeding
Correct Answer: A
Rationale: Uterine contractions (regular frequent) are the hallmark of preterm labor occurring before 37 weeks. Fetal macrosomia maternal fever and painless bleeding are not characteristic.
A client who has gout is most likely to form which type of renal calculi?
- A. Struvite stones
- B. Staghorn calculi
- C. Uric acid stones
- D. Calcium stones
Correct Answer: C
Rationale: The presence of urinary tract infection is a factor in the formation of struvite stones. Staghorn calculi is the other name for struvite stones associated with urinary tract infection. Clients who have gout form uric acid stones. Clients who have increased urinary excretion of calcium form calcium stones.
A 14-year-old boy has had diabetes for 7 years. He takes 30 U of NPH insulin and 10 U of regular insulin every morning at 7 AM. He eats breakfast at 7:30 AM and lunch at noon. What time should he expect the greatest risk for hypoglycemia?
- A. 9:00 AM
- B. 1:00 PM
- C. 11:00 AM
- D. 3:00 PM
Correct Answer: C
Rationale: This time is incorrect because regular insulin would peak after the teenager has eaten breakfast. This time is incorrect because it is after lunch when the NPH peaks. Regular insulin peaks in 2-3 hours and has a duration of 4-6 hours. NPH insulin's onset is 4-6 hours and peaks in 8-16 hours. Blood sugar would peak after meals and be lowest before meals and during the night. This time is incorrect because it is before the NPH and after the regular insulin peak times.
While reading the progress notes on a client with cancer, the nurse notes a TNM classification of T1, N1, M0. What does this classification indicate?
- A. The tumor is in situ, no regional lymph nodes are involved, and there is no metastasis.
- B. No evidence of primary tumor exists, lymph nodes can't be assessed, and metastasis can't be assessed.
- C. The tumor is extended, with regional lymph node involvement and distant metastasis.
- D. The tumor is extended and regional lymph nodes are involved, but there is no metastasis.
Correct Answer: D
Rationale: T1 indicates a small tumor, N1 indicates regional lymph node involvement, and M0 indicates no distant metastasis. Option A is incorrect (T1 is not in situ), B is incorrect (T0, not T1, means no tumor), and C is incorrect (M0 means no metastasis).