Nokea
To prepare the irrigation solution used for removal of cerumen, the nurse should use:
- A. Normal saline.
- B. Sterile water.
- C. Antiseptic solution.
- D. Warm tap water.
Correct Answer: A
Rationale: Normal saline is the preferred solution for ear irrigation, as it is isotonic and safe for the ear canal, minimizing irritation or risk of infection.
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During the previous few months, a 56-year-old woman felt brief twinges of chest pain while working in her garden and has had frequent episodes of indigestion. She comes to the hospital after experiencing severe anterior chest pain while raking leaves. Her evaluation confirms a diagnosis of stable angina pectoris. After stabilization and treatment, the client is discharged from the hospital. At her follow-up appointment, she is discouraged because she is experiencing pain with increasing frequency. She states that she visits an invalid friend twice a week and now cannot walk up the second flight of steps to the friend's apartment without pain. Which of the following measures that the nurse could suggest would most likely help the client prevent this problem?
- A. Visit her friend early in the day.
- B. Rest for at least an hour before climbing the stairs.
- C. Take a nitroglycerin tablet before climbing the stairs.
- D. Lie down once she reaches the friend's apartment.
Correct Answer: C
Rationale: Taking sublingual nitroglycerin before exertion (e.g., climbing stairs) prevents angina by dilating coronary arteries, increasing myocardial oxygen supply.
The nurse is supervising a newly hired nurse administer prescribed medications via a double-lumen nasogastric tube (NGT) with an air vent. Which action by the newly hired nurse requires follow-up?
- A. irrigates the air vent before medication administration with water.
- B. contacts the pharmacy to obtain available medications in liquid form.
- C. flushes the NGT between medications with water.
- D. administers each medication separately through the NGT.
Correct Answer: A
Rationale: The air vent of an NGT should not be irrigated, as it is for air passage, not medication or fluid administration.
A nurse is teaching a client with type 1 diabetes mellitus who jogs daily about the preferred sites for insulin absorption. What is the most appropriate site for a client who jogs?
- A. Arms.
- B. Legs.
- C. Abdomen.
- D. Iliac crest.
Correct Answer: C
Rationale: The abdomen is the preferred insulin injection site for active individuals like joggers, as it provides consistent absorption and is less affected by exercise compared to the legs.
A client with a hemorrhagic stroke is slightly agitated, heart rate is 118, respirations are 22, bilateral rhonchi are auscultated, SpO2 is 94%, blood pressure is 144/88, and oral secretions are noted. What order of interventions should the nurse follow when suctioning the client to prevent increased intracranial pressure (ICP) and maintain adequate cerebral perfusion?
- A. Suction the airway.
- B. Hyperoxygenate.
- C. Suction the mouth.
- D. Provide sedation.
Correct Answer: B,D,A,C
Rationale: The correct order is: 1) Hyperoxygenate to prevent hypoxia (B); 2) Provide sedation to reduce agitation and ICP spikes (D); 3) Suction the airway to clear secretions (A); 4) Suction the mouth to remove residual secretions (C). This sequence minimizes ICP increases and ensures oxygenation.
The nurse interprets which of the following as an early sign of acute respiratory distress syndrome (ARDS) in a client at risk?
- A. Elevated carbon dioxide level.
- B. Hypoxia not responsive to oxygen therapy.
- C. Metabolic acidosis.
- D. Severe, unexplained electrolyte imbalance.
Correct Answer: B
Rationale: Hypoxia unresponsive to oxygen therapy is an early ARDS sign due to impaired gas exchange. Elevated CO2, metabolic acidosis, and electrolyte imbalances occur later or are unrelated.