Nokea
When suctioning a client with a tracheostomy, when is the best time to occlude the vent on the suction catheter?
- A. Before inserting the catheter
- B. When inside the inner cannula
- C. While withdrawing the catheter
- D. When the client begins coughing
Correct Answer: C
Rationale: Occluding the vent while withdrawing the catheter applies suction to remove secretions effectively.
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An adult is to have a thoracentesis performed. What should the nurse do while preparing the client for this procedure?
- A. Keep him NPO for eight hours
- B. Prepare him to go to the operating room
- C. Explain the procedure to him
- D. Administer anticholinergic and analgesic as ordered
Correct Answer: C
Rationale: Explaining the procedure reduces anxiety and ensures the client understands what to expect during thoracentesis.
To evaluate the significance of the client's bleeding, which additional assessment is most important for the nurse to make at this time?
- A. Count the pulse rate.
- B. Listen to heart sounds.
- C. Check the pupillary response.
- D. Measure the chest expansion.
Correct Answer: D
Rationale: Measuring chest expansion helps assess for complications like pneumothorax, which could cause bleeding post-bronchoscopy.
The nurse in a long-term care facility is planning the care for a client with a percutaneous endoscopic gastrostomy (PEG) feeding tube used for bolus feedings. Which intervention should the nurse include in the plan of care?
- A. Inspect the insertion line at the naris prior to instilling formula.
- B. Elevate the head of the bed (HOB) after feeding the client.
- C. Place the client in the Sims position following each feeding.
- D. Change the dressing on the feeding tube every three (3) days.
Correct Answer: B
Rationale: Elevating HOB post-feeding (B) prevents aspiration in PEG clients. Naris inspection (A) applies to NG tubes, Sims position (C) is not standard, and dressings (D) are changed PRN.
Select all the medications used to treat pneumonia that are narrowspectrum?
- A. Macrolides
- B. Tamiflu
- C. Fluroquinolones
- D. Penicillins
Correct Answer: A,D
Rationale: Narrow-spectrum antibiotics target specific bacteria. Macrolides and Penicillins are narrow-spectrum, effective against gram-positive bacteria common in pneumonia. Tamiflu is antiviral, and Fluoroquinolones are broad-spectrum.
The nurse is assessing the client diagnosed with COPD. Which data require immediate intervention by the nurse?
- A. Large amounts of thick white sputum.
- B. Oxygen flowmeter set on eight (8) liters.
- C. Use of accessory muscles during inspiration.
- D. Presence of a barrel chest and dyspnea.
Correct Answer: B
Rationale: High oxygen (8 LPM, B) risks CO2 retention in COPD, requiring immediate adjustment (2–4 LPM). Sputum (A), accessory muscles (C), and barrel chest (D) are expected but less urgent.