Nokea
A patient with a cuffed tracheostomy tube in place after surgery.
The nurse knows the purpose of the cuff on the tracheostomy tube is to
- A. guarantee secure placement of the tracheostomy tube in the airway.
- B. prevent ischemia of the tracheal wall by distributing the pressure applied to it.
- C. decrease the chance of aspiration into the trachea.
- D. protect the trachea from ischemia and edema.
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) inaccurate, not the purpose of the cuff on a tracheostomy tube (2) complication of using a cuffed tracheostomy tube (3) correct-seals trachea, helps to prevent aspiration (4) trauma from overinflated tube may cause edema
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A client with hyperthyroidism.
Which of the following actions, if taken by the nurse, is BEST?
- A. Provide the client with extra blankets.
- B. Instill artificial tears prn.
- C. Offer the client reading material.
- D. Offer frequent low-calorie snacks.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) client is usually sensitive to heat (2) correct-clients with hyperthyroidism frequently exhibit exophthalmos, which requires ophthalmic drops on a regular basis (3) should provide a calm, restful environment with low levels of sensory stimulation, protecting eyes from injury takes priority (4) frequent snacks should be high-calorie
The nurse is teaching parents of an infant about introduction of solid food to their baby. What is the first food they can add to the diet?
- A. Vegetables
- B. Cereal
- C. Fruit
- D. Meats
Correct Answer: B
Rationale: Cereal is usually introduced first because it is well tolerated, easy to digest, and contains iron.
The nurse is caring for a client with a history of depression who is receiving venlafaxine (Effexor) 75 mg PO bid. Which of the following client statements would be of GREATest concern to the nurse?
- A. I feel tired in the afternoon.
- B. I have a dry mouth.
- C. I think about hurting myself.
- D. I take my medication with food.
Correct Answer: C
Rationale: Thoughts of hurting oneself indicate suicidal ideation, a medical emergency requiring immediate intervention in a client on venlafaxine. Options A, B, and D are less concerning: fatigue and dry mouth are common side effects, and taking with food is acceptable.
Which client should be assigned to the licensed practical nurse?
- A. The client maintained on ventilator support
- B. The client who has a cast applied for the treatment of a fractured femur
- C. The client who has just returned from the operating room with a thyroidectomy
- D. The client receiving interferon for the treatment of hepatitis
Correct Answer: B
Rationale: A client with a cast for a fractured femur is stable and suitable for an LPN. Ventilator support and post-op thyroidectomy require RN skills, and interferon administration needs specialized knowledge.
A child is admitted with acute glomerulonephritis. Which finding in the client's history is most consistent with the diagnosis?
- A. A recent tick bite
- B. Pharyngitis two weeks ago
- C. A mosquito bite last week
- D. Ingestion of foods high in uric acid
Correct Answer: B
Rationale: Acute glomerulonephritis is often post-streptococcal, following pharyngitis by 1-3 weeks, due to immune complex deposition in glomeruli. Tick bites, mosquito bites, or uric acid are unrelated.