Nokea
When suctioning a client's tracheostomy tube, the nurse should incorporate which of the following steps into the procedure?
- A. Oxygenate the client before suctioning.
- B. Insert the suction catheter about 2 inches into the cannula.
- C. Use a bolus of sterile water to stimulate coughing.
- D. Use clean gloves during the procedure.
Correct Answer: A
Rationale: Pre-oxygenation prevents hypoxia during tracheostomy suctioning, ensuring client safety.
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A client with a diagnosis of rheumatoid arthritis is prescribed adalimumab (Humira). The nurse should monitor the client for which of the following side effects?
- A. Infection.
- B. Hypotension.
- C. Weight gain.
- D. Hyperglycemia.
Correct Answer: A
Rationale: Adalimumab, a TNF inhibitor, increases the risk of infections due to immune suppression.
The nurse inserting an oropharyngeal airway into an assigned client should plan to use which insertion procedure?
- A. Flexing the client's neck
- B. Leaving dentures in place
- C. Suctioning the client's mouth only if prescribed
- D. Inserting the airway with the tip pointed upward
Correct Answer: D
Rationale: The airway is inserted with the tip pointed upward and is then rotated downward once the flange has reached the client's teeth. The client should be positioned supine, with the neck hyperextended if possible. Before insertion of an oropharyngeal airway, any dentures or partial plates should be removed from the client's mouth. After insertion, the client's mouth is suctioned every hour or as necessary. The airway is removed for inspection of the mouth every 2 to 4 hours.
The primary health care provider prescribes 650 mg of an antibiotic to be administered intravenously every 6 hours. The medication label reads as follows: reconstitute with 4.8 mL of bacteriostatic water to yield 2 g in 5 mL. How many mL should the nurse withdraw from the vial for 1 dose? Fill in the blank. Record the answer using 1 decimal place.
Correct Answer: 1.6 mL
Rationale: Convert 2 g to mg and then use the formula for calculating medication doses. In the metric system, to convert larger to smaller, multiply by 1000 or move the decimal 3 places to the right. Therefore, 2 g = 2000 mg. Formula: Desired / Available x Available Volume = 650 mg / 2000 mg x 5 mL = 1.625 mL = 1.6 mL.
The nurse caring for a client immediately following transurethral resection of the prostate (TURP) notices that the client has suddenly become confused and disoriented. The nurse determines that this may be a result of which potential complication of this surgical procedure?
- A. Hyponatremia
- B. Hypernatremia
- C. Hypochloremia
- D. Hyperchloremia
Correct Answer: A
Rationale: The client who suddenly becomes disoriented and confused after TURP could be experiencing early signs of hyponatremia. This may occur because the flushing solution used during the operative procedure is hypotonic. If enough solution is absorbed through the prostate veins during surgery, the client experiences increased circulating volume and dilutional hyponatremia. The nurse needs to report these symptoms. The conditions noted in the other options are not complications of the procedure.
After teaching a mother about the neonate's positive Babinski's reflex, the nurse determines that the mother understands the instructions when she says that a positive Babinski's reflex indicates:
- A. Possible partial paralysis.
- B. Possible lower limb defect.
- C. Immature central nervous system.
- D. Possible injury to nerves that innervate the legs.
Correct Answer: C
Rationale: A positive Babinski's reflex in neonates indicates an immature central nervous system, a normal finding that typically disappears by 1–2 years.