Nokea
When a chest tube is accidentally removed from a client, which of the following actions should the nurse NOT take first?
- A. Obtain a chest x-ray
- B. Apply sterile gauze to the insertion site
- C. Place tape around the insertion site
- D. Assess respiratory status
Correct Answer: B
Rationale: When a chest tube is accidentally removed, the priority action for the nurse is to immediately seal the insertion site with a gloved hand, a sterile occlusive dressing, or petroleum gauze to prevent air from entering the pleural space and causing a pneumothorax. Applying sterile gauze to the insertion site is not the correct initial action. The first step is to prevent respiratory compromise by ensuring the site is sealed. Therefore, the nurse should not apply sterile gauze to the insertion site first.
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When assessing a client with sinusitis, which technique should the nurse use to identify manifestations of this disorder?
- A. Percussion of the frontal sinuses
- B. Auscultation of the trachea
- C. Inspection of the nasal mucosa
- D. Palpation of the orbital areas
Correct Answer: D
Rationale: Sinusitis is an inflammation of the sinus cavities, which can cause tenderness and pain around the eyes (orbital areas). Palpation of the orbital areas can help identify tenderness and swelling associated with sinusitis. Auscultation of the trachea and percussion of the frontal sinuses are not relevant assessment techniques for sinusitis. Inspection of the nasal mucosa may reveal signs of inflammation, but palpation of the orbital areas is a more direct method to assess for tenderness and swelling in this specific condition.
A client has experienced a right-hemispheric stroke. Which of the following is not an expected finding?
- A. Impulse control difficulty
- B. Left hemiplegia
- C. Loss of depth perception
- D. Aphasia
Correct Answer: D
Rationale: In a right-hemispheric stroke, the expected findings include left-sided hemiplegia (Choice B), loss of depth perception (Choice C), and impulse control difficulty (Choice A). Aphasia (Choice D) is typically associated with left-hemispheric strokes. Therefore, aphasia is not an expected finding in a client who has experienced a right-hemispheric stroke.
A healthcare professional is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the healthcare professional NOT include in the plan of care?
- A. Have suction equipment available for use
- B. Feed the client thickened liquids
- C. Place food on the unaffected side of the client's mouth
- D. Assign an assistive personnel to feed the client slowly
Correct Answer: D
Rationale: When caring for a client with dysphagia, it is crucial to ensure safe feeding practices. Assigning an assistive personnel to feed the client slowly may not be appropriate as it can increase the risk of aspiration. Thickened liquids, having suction equipment available, and placing food on the unaffected side of the mouth are all appropriate measures to support a client with dysphagia in safe eating and drinking.
A nurse is orienting a newly licensed nurse on performing a routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching?
- A. Apply a vest restraint if self-extubation is attempted.
- B. Monitor ventilator settings every 8 hours.
- C. Document tube placement in centimeters at the angle of the jaw.
- D. Assess breath sounds every 1 to 2 hours.
Correct Answer: D
Rationale: Assessing breath sounds every 1 to 2 hours is crucial in monitoring the client's respiratory status and identifying any potential complications promptly. Monitoring ventilator settings every 8 hours is important for overall ventilation management. Documenting the endotracheal tube placement accurately is essential to ensure proper positioning. Using a vest restraint if self-extubation is attempted is not a recommended intervention as it can lead to complications and should be avoided.
A group of clients are being educated about influenza. Which of the following client statements indicates an understanding of the teaching?
- A. ''I should wash my hands after blowing my nose to prevent spreading the virus.''
- B. ''I need to avoid drinking fluids if I develop symptoms.''
- C. ''I need a flu shot every 2 years because of the different flu strains.''
- D. ''I should cover my mouth with my hand when I sneeze.''
Correct Answer: A
Rationale: The correct answer is, 'I should wash my hands after blowing my nose to prevent spreading the virus.' This statement shows understanding of the importance of hand hygiene in preventing the spread of influenza. Washing hands after activities like blowing the nose can help reduce the risk of transmitting the virus to others. Choices B, C, and D are incorrect as they do not reflect accurate understanding of influenza prevention measures.