Nokea
The nurse is to suction a client. What action is essential prior to inserting the suction catheter?
- A. Clear the mouth and throat of secretions.
- B. Lower the head of the bed.
- C. Oxygenate the client.
- D. Check the suction pressure.
Correct Answer: C
Rationale: Pre-oxygenation prevents hypoxia during suctioning, a critical step. Clearing secretions, lowering the bed, or checking pressure are secondary.
You may also like to solve these questions
The nurse is assigned a team with another registered nurse and an LPN.
Which of the following patients should the nurse assign to the LPN?
- A. A 67-year-old man who is NPO and scheduled for a transurethral resection of the prostate (TURP) in 3 hours.
- B. A 53-year-old woman with an IV of 0.9% NaCl at 100 cc/h who had a lumbar laminectomy two days ago.
- C. A 40-year-old woman with a Hemovac drain and a large surgical dressing from a mastectomy 2 days ago who is showing signs of depression.
- D. A 27-year-old woman scheduled for discharge later today after receiving chemotherapy through a portacath for treatment of leukemia.
Correct Answer: B
Rationale: Strategy: The LPN/LVN is assigned stable patients with expected outcomes. (1) needs preoperative teaching and assessment (2) correct-basic care needs can be met by the LPN/LVN, don't make patient assignments based on equipment (3) needs therapeutic intervention, teaching, and assessment (4) needs assessment and teaching
The nurse is caring for a client with pancreatitis experiencing the process of lipolysis of the pancreas. Which assessment would be a priority because of the pathophysiology of lipolysis?
- A. Checking for tetany-like movements
- B. Assessing breath sounds
- C. Obtaining vital signs
- D. Palpating pedal pulses
Correct Answer: A
Rationale: Hypocalcemia is a specific manifestation of clients with pancreatitis and lipolysis, and tetany is a major characteristic of low calcium levels. Answers B, C, and D are all pertinent assessments but are not priorities with the pathophysiology of lipolysis, so they are incorrect.
The nurse is caring for a client with a fractured femur in traction.
- A. What is the most appropriate action for the nurse if the client reports numbness in the affected leg?
- B. Reposition the traction weights.
- C. Check the pin sites for infection.
- D. Assess the neurovascular status of the leg.
- E. Administer pain medication as ordered.
Correct Answer: C
Rationale: Numbness in the affected leg suggests possible neurovascular compromise, requiring immediate assessment of circulation, sensation, and motor function. Adjusting traction, checking pin sites, or giving pain medication does not address the urgent need to evaluate neurovascular status.
The nurse is at the community center speaking with retired people about glaucoma. Which comment by one of the retirees would the nurse support to reinforce correct information?
- A. I usually avoid driving at night since lights sometimes seem to make things blur.'
- B. I take half of the usual dose for my sinuses to maintain my blood pressure.'
- C. I have to sit at the side of the pool with the grandchildren since I can't swim with this eye problem.'
- D. I take extra fiber and drink lots of water to avoid getting constipated.'
Correct Answer: D
Rationale: I take extra fiber and drink lots of water to avoid getting constipated.' Any activity that involves straining should be avoided in clients with glaucoma. Such activities would increase intraocular pressure.
The nurse is planning care for a client with a long history of smoking and newly diagnosed chronic obstructive pulmonary disease (COPD). Which of the following should the nurse include in the client's teaching plan?
- A. Explain the need to avoid large crowds during the winter months.
- B. Instruct the client to install air conditioning in the home.
- C. Teach the client to breathe in through the nose and out through the mouth.
- D. Encourage the client to consume three large meals daily.
Correct Answer: A
Rationale: Clients with COPD are at high risk for respiratory infections, which can exacerbate symptoms. Avoiding large crowds during winter reduces exposure to viruses. Options B, C, and D are less relevant: air conditioning is not essential, nasal breathing is not specific, and large meals can cause dyspnea due to gastric pressure.