Nokea
When suctioning the respiratory tract of a client, it is recommended that the suctioning period not exceed how many seconds?
- A. 5 seconds.
- B. 10 seconds.
- C. 15 seconds.
- D. 20 seconds.
Correct Answer: C
Rationale: Suctioning should not exceed 15 seconds to prevent hypoxia and trauma to the airway.
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The nurse is caring for a client with a suspected urinary tract infection. Which symptom is most common?
- A. Dysuria
- B. Flank pain
- C. Hematuria
- D. Nocturia
Correct Answer: A
Rationale: Dysuria (painful urination) is the most common symptom of a urinary tract infection, reflecting bladder or urethral irritation.
The nurse notices drops of a liquid on the hallway floor of a health care facility. The nurse should do which of the following first?
- A. Place paper towels over the drops of liquid.
- B. Don clean gloves and wipe up the drops of liquid.
- C. Post 'wet floor' signs around the area.
- D. Call the Environmental Services Department.
Correct Answer: C
Rationale: Posting 'wet floor' signs first ensures immediate safety by alerting others to the hazard, preventing slips. Then, the nurse can proceed with cleanup or notify appropriate personnel.
A postoperative client has a Jackson-Pratt drain. Which finding should the nurse report immediately?
- A. Clear, serous drainage.
- B. Bright red drainage of 50 mL in 2 hours.
- C. Slight swelling around the drain site.
- D. Drainage with a foul odor.
Correct Answer: B
Rationale: Bright red drainage suggests active bleeding, a serious complication requiring immediate reporting.
The nurse is teaching a client with a new diagnosis of asthma about the use of a spacer with a metered-dose inhaler. Which of the following instructions is most important?
- A. Shake the inhaler before attaching it to the spacer.
- B. Inhale quickly to maximize drug delivery.
- C. Clean the spacer with soap and water weekly.
- D. Use the spacer only during an asthma attack.
Correct Answer: C
Rationale: Cleaning the spacer weekly prevents bacterial buildup, ensuring safe and effective medication delivery.
A client with a history of chronic kidney disease is prescribed sodium polystyrene sulfonate (Kayexalate). The nurse should explain that this medication works by:
- A. Reducing blood pressure.
- B. Binding potassium in the gut.
- C. Increasing urine output.
- D. Decreasing blood glucose.
Correct Answer: B
Rationale: Sodium polystyrene sulfonate binds potassium in the gut, reducing serum potassium levels in chronic kidney disease.