Nokea
When suctioning a tracheostomy or laryngectomy tube, the nurse should follow which of the following procedures?
- A. Use a sterile catheter each time the client is suctioned.
- B. Clean the catheter in sterile water after each use and reuse for no longer than 8 hours.
- C. Protect the catheter in sterile packaging between suctioning episodes.
- D. Use a clean catheter with each suctioning, and disinfect it in hydrogen peroxide between uses.
Correct Answer: A
Rationale: Using a sterile catheter each time minimizes infection risk in the airway. Reusing catheters, even if cleaned, increases infection risk.
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A nurse is assessing a group of clients. Which clients are at risk for vasospastic disorder (Raynaud's phenomenon)?
- A. Young women
- B. Old women
- C. Old men
- D. Young men
Correct Answer: A
Rationale: Young women are at highest risk for Raynaud's phenomenon, particularly primary Raynaud's, due to hormonal influences and higher prevalence of autoimmune conditions. While men and older individuals can develop it, young women are most commonly affected.
The nurse is caring for an older adult in the emergency department with moderate hypothermia. Which of the following actions should the nurse take? Select all that apply.
- A. Apply external heat with a heating blanket to the client's trunk.
- B. Actively rewarm the extremities first, followed by the client's trunk.
- C. Use extracorporeal rewarming methods such as cardiopulmonary bypass or hemodialysis.
- D. Monitor for fluid, electrolyte, and metabolic abnormalities.
- E. Administer ordered medications at spaced longer intervals.
- F. Administer room temperature intravenous (IV) fluids for core rewarming.
Correct Answer: A,D,F
Rationale: Applying heat to the trunk (A), monitoring electrolytes (D), and using room-temperature IV fluids (F) are appropriate for moderate hypothermia. Rewarming extremities first (B) risks core afterdrop, extracorporeal methods (C) are for severe cases, and altering medication intervals (E) lacks evidence.
A client is scheduled to have an elective mandibular osteotomy to correct a mandibular fracture sustained in an accident 6 months earlier. Which statement by the client indicates to the nurse maladaptive coping?
- A. œI will be glad to have my jaw fixed because my wife thinks I do not look like myself.'
- B. œI am somewhat afraid to have the surgery but feel OK about it.'
- C. œMy wife will help me, but I don't think I will need that much help.'
- D. œI am ready to get this over with.'
Correct Answer: A
Rationale: The statement about the wife's perception suggests the client's motivation is external and may reflect poor self-image or reliance on others' opinions, indicating maladaptive coping. The other statements show acceptance, realistic fear, or confidence, which are more adaptive.
The client is to be discharged on a low-fat, low-cholesterol, low-sodium diet. Which of the following should be the nurse's first step in planning the dietary instructions?
- A. Determining the client's knowledge level about cholesterol.
- B. Asking the client to name foods that are high in fat, cholesterol, and salt.
- C. Explaining the importance of complying with the diet.
- D. Assessing the client's and family's typical food preferences.
Correct Answer: D
Rationale: Assessing food preferences ensures the dietary plan is tailored and practical.
A client with colon cancer is scheduled for chemotherapy post-resection. Which of the following should the nurse monitor for as a common side effect of chemotherapy?
- A. Hypertension.
- B. Nausea and vomiting.
- C. Hyperglycemia.
- D. Joint pain.
Correct Answer: B
Rationale: Nausea and vomiting are common side effects of chemotherapy due to its impact on rapidly dividing cells, including those in the gastrointestinal tract. Hypertension, hyperglycemia, and joint pain are less commonly associated with chemotherapy. CN: Pharmacological and parenteral therapies; CL: Analyze