Nokea
What should the nurse do when ambulating a client who has a portable wound drainage system?
- A. Remove the drainage catheter during ambulation
- B. Fasten the collection device below the wound
- C. Completely empty the collection device before ambulating
- D. Disconnect the suction apparatus from the client before ambulating
Correct Answer: B
Rationale: Fastening the drainage device below the wound promotes gravity-dependent drainage, preventing reflux and infection during ambulation.
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The nurse is preparing to suction a client who has a tracheostomy tube. Which of the following actions should the nurse take? Select all that apply.
- A. Administer 100% oxygen prior to suctioning the client
- B. Limit suctioning to 20 seconds during each suction pass
- C. Use sterile gloves and technique throughout the procedure
- D. Instill sterile normal saline into the tracheostomy tube prior to suctioning
- E. Apply suction while withdrawing the catheter from the tracheostomy tube
Correct Answer: A,C,E
Rationale: Pre-oxygenation, sterile technique, and suction on withdrawal prevent hypoxia and infection. Suctioning should be limited to 10-15 seconds, and saline instillation is not routinely recommended.
Home Medications
Vital signs
Temperature 98.5 F (36.9 C)
Blood pressure 110/74 mm Hg
Heart rate 68/min
Respirations 16/min
SpO2 97% on room air
Medication Prescription
Medication prescription
Clopidogrel: 75 mg PO, daily
Metoprolol XL: 50 mg PO, daily
Furosemide: 40 mg PO, twice daily
Fish oil: 4 g PO, daily
Intake and Output Record
Intake and output record
Time Oral Intake Output
0700 200 mL
0800 125 mL
1000 100 mL 250 mL
1200 200 mL 250 mL
1500 150 mL 375 mL
The nurse is caring for a client with coronary artery disease and heart failure. Which of the following findings would require immediate follow-up?
- A. bruises easily on the arms
- B. reports chronic fatigue
- C. muscle cramps in the legs
- D. reports feeling depressed
Correct Answer: C
Rationale: Hypokalemia (serum potassium <3.5 mEq/L [<3.5 mmol/L]) is a common adverse effect of potassium-wasting diuretics (eg,furosemide) that may cause leg cramps, muscle weakness, or ECG changes. Unmanaged hypokalemia can lead to lethal cardiac dyshythmias (eg, ventricular fibrillation, torsades de pointes) and paralysis. Therefore, the nurse should immediately notify the health care provider of symptoms of hypokalemia
An adult is being discharged on a low-sodium, low-fat diet. Which menu, if selected by the client, indicates an understanding of the diet?
- A. Hamburger with fries, apple pie, milkshake
- B. Tossed salad with vinaigrette dressing, baked skinny chicken, applesauce
- C. Steak, corn on the cob, fruit salad
- D. Fried shrimp, coleslaw, strawberry shortcake
Correct Answer: B
Rationale: Tossed salad, baked skinless chicken, and applesauce are low in sodium and fat, aligning with the prescribed diet.
An adult asks the nurse what could be causing him to have a black tongue and black stools. The following items are in the client's history. Which is most likely to be causing his symptoms?
- A. He is taking bismuth subsalicylate (Pepto-Bismol) for loose stools.
- B. He has been eating a lot of beets and broccoli recently.
- C. He has been taking iron tablets for anemia.
- D. He eats a lot of red meat.
Correct Answer: A
Rationale: Bismuth subsalicylate commonly causes black tongue and stools, a harmless side effect, unlike the other options.
The nurse is caring for a client with type 2 diabetes mellitus who is receiving a thiazolidinedione. Which of the following findings would require immediate follow-up?
- A. 2+ pitting edema in the lower legs bilaterally
- B. blood pressure of 140/88 mm Hg
- C. elevated triglyceride level
- D. elevated hemoglobin A1c
Correct Answer: A
Rationale: Thiazolidinediones (eg, rosiglitazone, pioglitazone) are oral antidiabetic medications used to manage hyperglycemia in clients with type 2 diabetes mellitus. Thiazolidinediones increase the sensitivity of insulin receptors, which improves insulin efficacy and prevents large rises in blood glucose after meals. It is a priority for the nurse to report signs of heart failure (eg, bilateral pitting edema, rapid weight gain, crackles) to the health care provider because thiazolidinediones can cause heart failure due to fluid retention. The client may require a lower thiazolidinedione dose or therapy with a different oral antidiabetic agent (eg, metformin).