Nokea
What is the purpose of the cuff in a Tracheostomy tube?
- A. Separate the upper and lower airway
- B. Separate trachea from the esophagus
- C. Separate the larynx from the nasopharynx
- D. Secure the placement of the tube
Correct Answer: B
Rationale: The purpose of the cuff in a Tracheostomy tube is to separate the trachea from the esophagus. The cuff helps prevent aspiration by creating a seal that separates the trachea from the esophagus, reducing the risk of food or fluids entering the lungs. Choices A, C, and D are incorrect because the cuff's primary function in a Tracheostomy tube is to prevent aspiration rather than separating the upper and lower airway, larynx from the nasopharynx, or securing the placement of the tube.
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What is the most appropriate instruction to provide to the parent of a child who does not like a food item?
- A. The child should not be encouraged to try it again.
- B. The child should be offered a reward if they eat most of the food items.
- C. The child should be offered the item at least 8 times on different occasions.
- D. The child should be encouraged to eat at least 5 bites of the food item.
Correct Answer: C
Rationale: The correct answer is C. Encouraging repeated exposure to the food item can help the child develop a taste for it. Option A is incorrect as it suggests avoiding encouraging the child to try the food again, which may hinder their ability to develop a liking for it. Option B is incorrect as using rewards for eating may not promote a genuine interest in the food item. Option D is incorrect because setting a specific number of bites may create pressure and negativity around mealtime, rather than fostering a positive association with the food.
When assessing Richard for chest percussion or chest vibration and postural drainage, Mario would focus on the following EXCEPT:
- A. Amount of food and fluid taken during the last meal before treatment
- B. Respiratory rate, breath sounds, and location of congestion
- C. Teaching the client's relatives to perform the procedure
- D. Doctor's order regarding position restrictions and client's tolerance for lying flat
Correct Answer: B
Rationale: The correct answer is B because when assessing Richard for chest percussion or chest vibration and postural drainage, Mario would focus on various aspects such as the amount of food and fluid taken before treatment to prevent complications during the procedure, teaching the client's relatives to perform the procedure correctly, and following the doctor's orders regarding position restrictions and the client's tolerance for lying flat. Respiratory rate, breath sounds, and location of congestion would be assessed during the procedure itself, not as part of the pre-assessment.
A patient is being discharged with a vitamin K deficiency. What food should the nurse recommend to the patient to include in their diet?
- A. Oranges
- B. Spinach
- C. Fish
- D. Nuts
Correct Answer: B
Rationale: Spinach is an excellent source of vitamin K, which plays a vital role in blood clotting and bone health. Oranges, fish, and nuts do not contain significant amounts of vitamin K, making them less suitable choices to address a vitamin K deficiency. Therefore, the correct recommendation for a patient with a vitamin K deficiency would be to include spinach in their diet to help replenish this essential vitamin.
Which of the following statements about Z-Track technique is false?
- A. Z-Track injections prevent irritation of the subcutaneous tissues
- B. The technique involves creating a Zig-Zag like pattern of medication
- C. It forces the medication to be contained in the subcutaneous tissues
- D. It is used when administering Parenteral Iron
Correct Answer: B
Rationale: The Z-Track technique is aimed at preventing medication leakage into the surrounding tissues by sealing the medication in the muscle, not by creating a Zig-Zag pattern. Choice A is correct as Z-Track injections help prevent irritation. Choice C is correct as it accurately describes how the technique works. Choice D is also correct as the Z-Track technique is commonly used when administering Parenteral Iron to prevent staining and irritation of the surrounding tissues.
The nurse notes that the fall might also cause a possible head injury. The patient will be observed for signs of increased intracranial pressure which include:
- A. Narrowing of the pulse pressure
- B. Vomiting
- C. Periorbital edema
- D. A positive Kernig's sign
Correct Answer: C
Rationale: Periorbital edema is a sign of increased intracranial pressure. It is caused by fluid accumulation around the eyes due to compromised drainage. Narrowing of the pulse pressure is more indicative of shock than increased intracranial pressure. While vomiting can be a sign of increased intracranial pressure, it is not as specific as periorbital edema. A positive Kernig's sign is associated with meningitis, not increased intracranial pressure.