Nokea
What principle of HIV disease should the nurse keep in mind when planning care for a newborn who was infected in utero?
- A. The disease will incubate longer and progress more slowly in this infant.
- B. The infant is very susceptible to infections.
- C. Growth and development patterns will proceed at a normal rate.
- D. Careful monitoring of renal function is indicated.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best?
- A. Elevate the head of the client's bed.
- B. Measure and compare cuff pressures.
- C. Place the client on NPO status.
- D. Request a swallow study for the client.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Tracheostomy cuff should be inflated to prevent aspiration.
2. Food particles indicate cuff leakage.
3. Measuring cuff pressure ensures proper sealing.
4. Prevents aspiration and respiratory complications.
Summary:
A: Elevating the head is beneficial but doesn't address cuff leakage.
C: NPO status is extreme and unnecessary without confirmation of aspiration risk.
D: Swallow study is for assessing swallowing function, not related to cuff pressure.
A client with chronic obstructive pulmonary disease (COPD) appears thin and disheveled. Which question should the nurse ask first?
- A. Do you have a strong support system?
- B. What do you understand about your disease?
- C. Do you experience shortness of breath with basic activities?
- D. What medications are you prescribed to take each day?
Correct Answer: C
Rationale: The correct question to ask first is C: "Do you experience shortness of breath with basic activities?" This is because shortness of breath is a common and concerning symptom in COPD patients that can greatly impact their quality of life and indicate disease progression. By addressing this symptom first, the nurse can assess the severity of the client's condition and determine the immediate need for intervention or treatment. Asking about support system (A) is important but not as urgent as addressing the primary symptom. Inquiring about the client's understanding of the disease (B) and medications (D) is also important but should come after addressing the immediate symptom of shortness of breath.
How will recognizing that clients have different perceptions of time assist the nurse to provide more sensitive care?
- A. Adapting care plans to accommodate varying time perspectives.
- B. Enforcing strict schedules regardless of cultural differences.
- C. Ignoring time-related preferences.
- D. None of the above.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
How many gtts per mL is delivered with microdrip tubing?
- A. 20 gtts per mL
- B. 10 gtts per mL
- C. 15 gtts per mL
- D. 60 gtts per mL
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which intervention can help a visually impaired client achieve independence?
- A. Keep personal care items in a different location each day
- B. Ask the client’s preference for where to store hygiene articles and other objects needed for self-care
- C. At mealtimes, ask the client to feel where food is on the plate
- D. Place meal tray on overbed tray and leave the room
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.