Nokea
When performing the client's tracheostomy care, which nursing action is correct?
- A. Cut a gauze square to fit around the client's stoma.
- B. Secure the ties at the back of the client's neck.
- C. Attach new ties before removing old ones.
- D. Replace the cannula after changing the ties.
Correct Answer: C
Rationale: Attaching new ties before removing old ones ensures the tracheostomy tube remains secure, preventing accidental dislodgement.
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The post-anesthesia care nurse is caring for the client diagnosed with lung cancer who had a thoracotomy and is experiencing frequent premature ventricular contractions (PVCs). Which intervention should the nurse implement first?
- A. Request STAT arterial blood gases.
- B. Administer lidocaine intravenous push.
- C. Assess for possible causes.
- D. Request a STAT electrocardiogram.
Correct Answer: C
Rationale: Frequent PVCs post-thoracotomy may stem from hypoxia, electrolyte imbalances, or pain. Assessing for causes (C) is the first step to identify and address the underlying issue. ABGs (A) or ECG (D) may follow based on findings. Lidocaine (B) is premature without identifying the cause.
Which information should the nurse teach the client diagnosed with acute sinusitis?
- A. Instruct the client to complete all the ordered antibiotics.
- B. Teach the client how to irrigate the nasal passages.
- C. Have the client demonstrate how to blow the nose.
- D. Give the client samples of a narcotic analgesic for the headache.
Correct Answer: A
Rationale: Completing antibiotics (A) ensures treatment of bacterial sinusitis, preventing resistance. Irrigation (B) is supportive, nose-blowing (C) is routine, and narcotics (D) are excessive for sinus headaches.
If the client complains of GI side effects associated with rifampin (Rifadin), which nursing action is best?
- A. Administering the drug at night
- B. Giving the drug with food or at mealtimes
- C. Encouraging the client to drink plenty of water
- D. Providing the client with an antacid
Correct Answer: B
Rationale: Giving rifampin with food can reduce gastrointestinal side effects, such as nausea, without compromising its efficacy.
A client comes to the clinic with a bloody nose. Which instruction is most appropriate?
- A. Sit up with your head tilted forward. Grasp the soft part of your nose firmly between your thumb and forefinger.'
- B. Lay down and tilt your head backward. Grasp the end of your nose between your fingers.'
- C. Sit up and lean backwards. Put pressure on the side of your nose with your hand.'
- D. Lie down with your head lower than your feet. Grasp as much of your nose as possible between your fingers.'
Correct Answer: A
Rationale: Sitting with the head tilted forward and grasping the soft part of the nose prevents aspiration of blood and effectively stops bleeding.
If the client develops a severe allergic reaction, which drug should the nurse have available?
- A. Codeine sulfate
- B. Morphine sulfate (Roxanol)
- C. Dopamine (Intropin)
- D. Epinephrine (Adrenalin)
Correct Answer: D
Rationale: Epinephrine is the first-line treatment for severe allergic reactions (anaphylaxis) as it reverses airway constriction and stabilizes blood pressure.