Nokea
When suctioning a client's tracheostomy, the nurse should instill saline in order to
- A. decrease the client's discomfort
- B. reduce viscosity of secretions
- C. prevent client aspiration
- D. remove a mucus plug
Correct Answer: D
Rationale: remove a mucus plug. While no longer recommended for routine suctioning, saline may thin and loosen viscous secretions that are very difficult to move, perhaps making them easier to suction.
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A patient with effective pain relief.
Which of the following nursing actions is MOST important to provide a patient with effective pain relief?
- A. Teach the patient about his pain.
- B. Establish a trusting relationship with the patient.
- C. Determine how various relaxation techniques affect the pain.
- D. Provide alternative measures to relieve pain.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) not most important (2) correct-necessary to work with patient to identify interventions to relieve pain (3) part of intervention and evaluation phase (4) only a portion of interventions used to relieve pain
The nurse is caring for a client who is receiving IV fluids at 125 mL/hour. Which of the following findings should the nurse report immediately?
- A. Blood pressure of 130/80 mmHg.
- B. Heart rate of 80 bpm.
- C. Shortness of breath and crackles.
- D. Urine output of 50 mL/hour.
Correct Answer: C
Rationale: Shortness of breath and crackles suggest fluid overload, a serious complication. Options A, B, and D are normal.
Which of the following statements best describes the gross motor development of a 2-year old?
- A. She skips without falling.
- B. She walks up and down stairs.
- C. She rides a tricycle.
- D. She is able to broad jump.
Correct Answer: B
Rationale: A 2-year-old can typically walk up and down stairs with support, a key gross motor milestone. Skipping , riding a tricycle , and broad jumping are skills developed later, around 3-5 years.
A client admitted with acute hypoparathyroidism.
It is MOST important for the nurse to have which of the following items available?
- A. Tracheostomy set.
- B. Cardiac monitor.
- C. IV monitor.
- D. Heating pad.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-tracheostomy set is the most important for the client's safety due to risk for laryngospasm (2) nice to have, but not the most important (3) nice to have, but not the most important (4) unnecessary
The nurse discusses symptoms of the onset of labor with a 26-year-old primipara. Which of the following statements, if made by the client to the nurse, indicates a need for further teaching?
- A. I will note an increase in fetal movement.
- B. I may feel a gush of fluid run down my legs.
- C. I may see some blood in my vaginal discharge.
- D. I may experience a low backache.
Correct Answer: A
Rationale: Fetal movement decreases at labor onset due to limited space; expecting an increase indicates misunderstanding. Options B, C, and D are correct labor signs.