Nokea
What intervention should a nurse use when the client is unable to cough and raise secretions?
- A. Give the client water to drink.
- B. Pat the client on the back.
- C. Gently suction the client.
- D. Give the client cough syrup.
Correct Answer: C
Rationale: Gentle suctioning effectively removes secretions, preventing respiratory complications.
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If a client denies having a hearing impairment, which question would encourage them to respond?
- A. Do you always ask people to repeat questions? If so, do you think that you have a hearing problem?
- B. Are you cupping your ear for a reason? Do you have trouble hearing?
- C. Both A and B
- D. Neither A nor B
Correct Answer: C
Rationale: Asking open-ended questions increases the likelihood of acknowledgment and discussion of the issue.
How should the nurse position Mr. Jones’ chest drainage unit while he is transported?
- A. Below the chest level
- B. On the stretcher
- C. The unit should be removed
- D. The tubes should be clamped
Correct Answer: A
Rationale: The correct answer is A: Below the chest level. Positioning the chest drainage unit below the chest level allows for effective drainage of air or fluid from the chest cavity. Placing it above the chest level may cause backflow or air/fluid accumulation. Option B is incorrect as the unit should be secured to prevent dislodging during transport. Option C is incorrect as removing the unit can lead to complications. Option D is incorrect as clamping the tubes can result in a tension pneumothorax. Positioning the unit below the chest level ensures proper drainage and prevents complications during transport.
When performing tracheostomy care, which intervention should the nurse implement?
- A. Use aseptic technique.
- B. Clean the inner cannula with mild soap and water.
- C. Secure new tracheostomy ties before removing old ones.
- D. Apply suction when inserting the catheter.
Correct Answer: C
Rationale: The correct answer is C: Secure new tracheostomy ties before removing old ones. This is essential to ensure the patient's airway remains stable and secure during the procedure. By securing the new ties first, the tracheostomy tube will not accidentally dislodge or become displaced.
A: Using aseptic technique is important but not the immediate priority in this situation.
B: Cleaning the inner cannula is a routine part of tracheostomy care but not the primary intervention during tie change.
D: Applying suction when inserting the catheter is incorrect as suctioning should be performed after securing the new ties to maintain airway patency.
A client is vomiting. Which of the following actions should the nurse take first?
- A. Provide the client with an emesis basin
- B. Notify housekeeping
- C. Prevent the client from aspirating
- D. Administer an antiemetic to the client
Correct Answer: C
Rationale: The correct action for the nurse to take first is to prevent the client from aspirating. Aspiration is a serious risk when a client is vomiting as it can lead to respiratory complications. The nurse should position the client on their side to prevent aspiration of vomitus into the airway. This immediate action takes priority over providing an emesis basin, notifying housekeeping, or administering an antiemetic, which do not address the urgent need to prevent aspiration.
Which chief complaint is NOT desirable for recording on the client’s chart?
- A. CC: “cough and temperature elevation,” 2 days duration
- B. CC: “passing black stools,” 1 day duration
- C. CC: “substernal pain,” 2 hours duration
- D. Reason for contact: “physical examination for college”
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Chief complaints should be symptoms or concerns related to the client's health issues.
2. "Physical examination for college" is not a specific symptom or health concern.
3. Chief complaints guide healthcare providers in assessing and treating the client.
4. Recording irrelevant chief complaints can lead to confusion in diagnosis and treatment.
Summary of Incorrect Choices:
A: Describes specific symptoms, suitable for recording.
B: Describes a specific symptom (black stools), suitable for recording.
C: Describes a specific symptom (substernal pain), suitable for recording.