Nokea
When performing tracheostomy care, which intervention should the nurse implement?
- A. Use aseptic technique.
- B. Clean the inner cannula with mild soap and water.
- C. Secure new tracheostomy ties before removing old ones.
- D. Apply suction when inserting the catheter.
Correct Answer: C
Rationale: The correct answer is C: Secure new tracheostomy ties before removing old ones. This is essential to ensure the patient's airway remains stable and secure during the procedure. By securing the new ties first, the tracheostomy tube will not accidentally dislodge or become displaced.
A: Using aseptic technique is important but not the immediate priority in this situation.
B: Cleaning the inner cannula is a routine part of tracheostomy care but not the primary intervention during tie change.
D: Applying suction when inserting the catheter is incorrect as suctioning should be performed after securing the new ties to maintain airway patency.
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When should discharge planning begin for a patient in a tertiary-care facility?
- A. On the day of admission
- B. After the acute crisis is resolved
- C. When the physician writes the discharge order
- D. When the patient demonstrates readiness to discuss posthospitalization needs
Correct Answer: A
Rationale: Rationale:
A: Discharge planning should begin on the day of admission to ensure a smooth transition. This early start allows for comprehensive assessment and coordination of post-discharge needs.
B: Waiting until after the acute crisis is resolved may lead to rushed planning and potential gaps in care.
C: Discharge planning should not solely rely on the physician's discharge order as it may not address all aspects of the patient's needs.
D: Patient readiness is important, but starting planning early ensures sufficient time for assessment and interventions.
What is the purpose and advantage of methadone maintenance therapy?
- A. Increased alertness
- B. Lower immune response
- C. Faster metabolism
- D. Enhanced digestion
Correct Answer: C
Rationale: The correct answer is C because it is the most appropriate response based on physiological and medical principles.
A client had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?
- A. Poor impulse control
- B. Inability to discriminate words and letters
- C. Deficits in the right visual field
- D. Motor retardation
Correct Answer: A
Rationale: The correct answer is A: Poor impulse control. When a client has a stroke involving the right cerebral hemisphere, it can affect their ability to regulate emotions and impulses. The right hemisphere is responsible for inhibiting impulsive behavior, so damage to this area can lead to poor impulse control. This can manifest as impulsivity, lack of judgement, and difficulty controlling emotions.
Summary of Incorrect Choices:
B: Inability to discriminate words and letters - This is typically associated with left cerebral hemisphere damage, not right hemisphere.
C: Deficits in the right visual field - This is associated with damage to the left occipital lobe, not the right hemisphere.
D: Motor retardation - Motor functions are controlled by the opposite side of the brain, so right hemisphere damage would typically affect the left side of the body, not motor function in general.
Exercise can improve circulation and cardiovascular fitness by decreasing
- A. The number of small blood vessels throughout the body
- B. The heart rate and blood pressure
- C. High-density lipoproteins (HDL) in the blood
- D. The body’s breathing capacity
Correct Answer: B
Rationale: The correct answer is B because exercise can improve circulation and cardiovascular fitness by reducing the heart rate and blood pressure. When we exercise, our heart becomes more efficient at pumping blood, leading to a lower resting heart rate and reduced blood pressure. This helps improve circulation and strengthens the cardiovascular system.
Explanation for why the other choices are incorrect:
A: The number of small blood vessels throughout the body - Exercise actually promotes the growth of new blood vessels, improving circulation.
C: High-density lipoproteins (HDL) in the blood - Exercise can increase HDL levels, which is beneficial for heart health.
D: The body’s breathing capacity - Exercise can improve lung function and increase breathing capacity, but it is not directly related to circulation or cardiovascular fitness.
Which of the following is a finding that is most often associated with endometrial cancer?
- A. Thickened endometrial lining on ultrasound
- B. Irregular periods
- C. Young age
- D. Dyspareunia
Correct Answer: A
Rationale: A thickened endometrial lining on ultrasound is commonly associated with endometrial cancer, indicating abnormal cell growth.