Nokea
To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must
- A. apply suction for no more than 10 seconds
- B. maintain sterile technique
- C. lubricate 3 to 4 inches of the catheter tip
- D. withdraw catheter in a circular motion
Correct Answer: A
Rationale: Applying suction for more than 10 seconds may result in hypoxia. Although options B, C, and D are important during suctioning a tracheostomy, hypoxia results from actions that decrease the oxygen supply.
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A client is admitted with a tentative diagnosis of congestive heart failure. Which of the following assessments would the nurse expect to be consistent with this problem?
- A. Chest pain
- B. Pallor
- C. Inspiratory crackles
- D. Heart murmur
Correct Answer: C
Rationale: Inspiratory crackles. In congestive heart failure, fluid backs up into the lungs (creating crackles) as a result of inefficient cardiac pumping.
The HCP is about to examine the client on contact precautions for MRSA without donning PPE. Which is the best action by the nurse?
- A. Hand the provider a gown and gloves
- B. Not say anything; it is the HCP's decision
- C. Notify the charge nurse and unit manager
- D. Monitor for increased infections on the unit
Correct Answer: A
Rationale: A: Providing PPE ensures immediate compliance with contact precautions. B: Ignoring the breach risks transmission. C, D: These actions delay intervention.
A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first?
- A. Ask client to cough sputum into container
- B. Have the client take several deep breaths
- C. Provide an appropriate specimen container
- D. Assist with oral hygiene
Correct Answer: D
Rationale: Assist with oral hygiene. Obtain a specimen early in the morning after mouth care. The other responses follow this first action: the client should take several deep breaths then cough into the appropriate sterile container to obtain the AFB specimen of the sputum.
Although nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Motrin) are beneficial in managing arthritis pain, the nurse should caution clients about which of the following common side effects?
- A. Urinary incontinence
- B. Constipation
- C. Nystagmus
- D. Occult bleeding
Correct Answer: D
Rationale: Occult bleeding. Nonsteroidal anti-inflammatory drugs (NSAIDs) taken for long periods of time may cause serious side effects, including bleeding in the gastrointestinal tract.
A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers?
- A. A 79 year-old malnourished client on bed rest
- B. An obese client who uses a wheelchair
- C. An incontinent client who has had 3 diarrhea stools
- D. An 80 year-old ambulatory diabetic client
Correct Answer: A
Rationale: A 79 year-old malnourished client on bed rest. Weighing significantly less than ideal body weight increases the number and surface area of bony prominences which are susceptible to pressure ulcers. Thus, malnutrition is a major risk factor for decubiti, due in part to poor hydration and inadequate protein intake.