Nokea
When suctioning the airway of a client with a tracheostomy, the nurse applies suction for no longer than how many seconds?
- A. 5 to 7
- B. 10 to 12
- C. 15 to 20
- D. 25 to 30
Correct Answer: B
Rationale: Suctioning for 10 to 12 seconds minimizes the risk of hypoxia and mucosal trauma.
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Which statement best suggests that the client understands the nurse's instruction on how to handle the sputum specimen container?
- A. I should wipe the container with an alcohol swab.
- B. I must not touch the inside of the container.
- C. I cannot put the lid on the container until the container is fairly full.
Correct Answer: B
Rationale: Not touching the inside of the container prevents contamination, ensuring an accurate sputum sample.
When teaching the client about topical nasal decongestant sprays, the nurse should warn that overuse of such medication is likely to result in which adverse effect?
- A. Nasal irritation with rhinorrhea
- B. Rebound congestion with nasal stuffiness
- C. Ulceration of the nasal mucous membranes
- D. Decreased ability to fight microorganisms
Correct Answer: B
Rationale: Overuse of topical nasal decongestants can lead to rebound congestion, where nasal passages become more congested after the medication wears off, due to dependency on the decongestant.
The nurse is caring for the client diagnosed with COPD. Which outcome requires a revision in the plan of care?
- A. The client has no signs of respiratory distress.
- B. The client shows an improved respiratory pattern.
- C. The client demonstrates intolerance to activity.
- D. The client participates in establishing goals.
Correct Answer: C
Rationale: Activity intolerance (C) indicates poor COPD control, requiring plan revision. No distress (A), improved breathing (B), and goal participation (D) are positive outcomes.
When caring for a client with a flail chest, which nursing action is most appropriate?
- A. Suction the client's airway.
- B. Tape the chest securely.
- C. Apply a chest binder.
- D. Encourage coughing.
Correct Answer: C
Rationale: Applying a chest binder stabilizes the flail chest, reducing paradoxical chest movement and improving ventilation.
When the client undergoes scratch skin testing, which sign best indicates a hypersensitivity to the scratched substance?
- A. The skin at the test site feels numb.
- B. The skin at the test site feels painful.
- C. The skin at the test site looks red.
Correct Answer: C
Rationale: A positive skin test reaction is indicated by redness and swelling at the test site, showing a hypersensitivity response to the allergen.