Nokea
The nurse performing tracheostomy care has replaced the tracheostomy tube holder (tracheostomy ties). Which is an effective measure for the nurse to use when determining if the holder is not too tight?
- A. The client nods that he or she feels comfortable.
- B. Two fingers can be slid comfortably under the holder.
- C. Four fingers can be slid comfortably under the holder.
- D. The tracheostomy does not move more than 0.5 inch when the client coughs.
Correct Answer: B
Rationale: There should be enough room for two fingers to slide comfortably under the tracheostomy holder. This ensures that the holder is tight enough to prevent tracheostomy dislocation, while preventing excessive constriction around the neck. The other options are incorrect.
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The nurse is caring for a client with a chest tube in place for a pneumothorax. Which of the following findings indicates that the chest tube is functioning properly?
- A. Continuous bubbling in the water seal chamber.
- B. Absence of tidaling in the water seal chamber.
- C. Fluctuation of fluid in the drainage tube with respiration.
- D. No drainage in the collection chamber.
Correct Answer: C
Rationale: Fluctuation (tidaling) in the drainage tube with respiration indicates the chest tube is patent and functioning to remove air or fluid.
The nurse teaches a client taking desmopressin (DDAVP) nasal spray about how to manage treatment. The nurse determines that the client needs additional instruction when he makes which of the following comments?
- A. I should check for sores in my nose while taking this medication.'
- B. I should use the same nostril each time I take the medicine.'
- C. I should report nasal congestion.'
- D. I should report any signs of respiratory infection.'
Correct Answer: B
Rationale: Using the same nostril each time can cause irritation or reduced efficacy; alternating nostrils is recommended. The other comments reflect correct understanding of desmopressin use.
A client with a diagnosis of gout is prescribed febuxostat (Uloric). The nurse should instruct the client to:
- A. Take the medication with food to reduce stomach upset.
- B. Avoid drinking alcohol.
- C. Limit fluid intake.
- D. Take the medication at bedtime only.
Correct Answer: A,B
Rationale: Taking febuxostat with food reduces gastrointestinal upset, and avoiding alcohol prevents uric acid buildup.
The nurse is preparing a presentation on nutrition to a group of pregnant adolescents. Which of the following would be important for the nurse to include in the teaching plan?
- A. Spinach is an excellent source of calcium in the diet.
- B. Two to four servings of whole-grain products is recommended.
- C. Three or more servings of dairy products meet the calcium requirement.
- D. Vitamin A supplements may be necessary for clients who are vegetarian.
Correct Answer: C
Rationale: Three or more servings of dairy products provide adequate calcium, essential for fetal development and maternal bone health during pregnancy.
A client has been diagnosed with Bell's palsy. The nurse assesses the client to determine if which signs/symptoms are present?
- A. Eye paralysis and ptosis of the eyelids
- B. Chewing difficulties and one-sided facial droop
- C. Fixed pupil and an elevated eyelid on one side
- D. Twitching of one side of the face and ruddy cheeks
Correct Answer: B
Rationale: Bell's palsy is a one-sided facial paralysis resulting from compression of the facial nerve (CN VII). There is facial droop from paralysis of the facial muscles; increased lacrimation; painful sensations in the eye, face, or behind the ear; and chewing difficulties. The other items listed are not associated with this disorder.