Nokea
What is an early sign that suctioning is needed for a client with a tracheostomy?
- A. Bradycardia
- B. Irritability
- C. Hypotension
- D. Decreased oxygen saturation
Correct Answer: B
Rationale: Irritability is an early sign that suctioning is needed for a client with a tracheostomy. When secretions accumulate in the airway, it can lead to discomfort and irritability in the client. Bradycardia, hypotension, and decreased oxygen saturation are usually later signs of inadequate airway clearance and oxygenation. Bradycardia may indicate severe hypoxia, while hypotension and decreased oxygen saturation are consequences of prolonged airway obstruction.
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A client is learning about preventing hip dislocation before total hip arthroplasty. Which instruction should be included?
- A. Avoid bending the hip more than 90 degrees
- B. Avoid lying on the unaffected side
- C. Avoid crossing the legs at the knees
- D. Avoid keeping the legs in a neutral position
Correct Answer: C
Rationale: The correct instruction to prevent hip dislocation after total hip arthroplasty is to avoid crossing the legs at the knees. This position can put stress on the hip joint and increase the risk of dislocation. Choices A, B, and D are incorrect. Bending the hip more than 90 degrees, lying on the unaffected side, or keeping the legs in a neutral position are not directly related to preventing hip dislocation in this context.
A client with coronary artery disease (CAD) is being taught about lifestyle changes by a nurse. Which of the following instructions should the nurse include?
- A. Increase your intake of red meat
- B. Increase physical activity to 150 minutes per week
- C. Avoid foods high in fiber
- D. Increase sodium intake to 2,300 mg per day
Correct Answer: B
Rationale: The correct answer is B: 'Increase physical activity to 150 minutes per week.' Increasing physical activity is essential for clients with CAD as it helps reduce the risk of cardiovascular events. Choice A is incorrect as red meat is high in saturated fats, which can be detrimental for CAD. Choice C is incorrect as foods high in fiber, such as fruits, vegetables, and whole grains, are beneficial for heart health. Choice D is incorrect as increasing sodium intake can lead to hypertension and worsen CAD.
What is the role of a nurse in managing a patient with acute kidney injury (AKI)?
- A. Monitor urine output and electrolyte levels
- B. Administer diuretics and restrict potassium
- C. Provide dietary education and monitor fluid intake
- D. Administer antibiotics and check for dehydration
Correct Answer: A
Rationale: The correct answer is A: 'Monitor urine output and electrolyte levels.' In managing a patient with acute kidney injury (AKI), it is crucial for the nurse to monitor urine output and electrolyte levels to assess kidney function and the patient's fluid and electrolyte balance. This monitoring helps in early detection of any worsening kidney function or electrolyte imbalances. Choice B is incorrect because administering diuretics and restricting potassium may not be appropriate for all AKI patients and should be done under the direction of a healthcare provider. Choice C is also incorrect as providing dietary education and monitoring fluid intake are important but do not directly address the immediate management of AKI. Choice D is incorrect as administering antibiotics and checking for dehydration are not primary interventions for managing AKI; antibiotics are only given if there is an infection contributing to AKI, and dehydration should be managed but is not the primary role of the nurse in AKI management.
A nurse is providing dietary teaching to a client who has chronic kidney disease. Which of the following food choices by the client indicates an understanding of the teaching?
- A. Canned soup
- B. Grilled chicken
- C. Peanut butter
- D. Orange juice
Correct Answer: B
Rationale: Grilled chicken is the correct choice as it is a low-potassium, low-sodium option suitable for clients with chronic kidney disease. Canned soup (choice A) is typically high in sodium, which is not recommended for this client population. Peanut butter (choice C) is high in potassium and phosphorus, which should be limited in individuals with kidney disease. Orange juice (choice D) is high in potassium and should be consumed in moderation by clients with chronic kidney disease.
A nurse is caring for a client who has a terminal illness and is approaching death. Which of the following findings should the nurse identify as an indication of impending death?
- A. Hypertension.
- B. Tachycardia.
- C. Cold extremities.
- D. Diaphoresis.
Correct Answer: C
Rationale: Cold extremities are a critical sign of impending death as they indicate decreased circulation, leading to poor perfusion to the extremities. This phenomenon occurs as the body redirects blood flow to vital organs, preparing for the end of life. Hypertension and tachycardia are less likely to be seen in the terminal phase and are usually associated with other conditions like shock or sepsis. Diaphoresis, or excessive sweating, may occur in various situations but is not a specific indicator of impending death in this context.