Nokea
Which assessment finding provides the best indication that the nurse needs to suction the client with a tracheostomy?
- A. Respirations are low.
- B. Pulse rate is slow.
- C. Breath sounds are wet.
- D. Blood pressure is elevated.
Correct Answer: C
Rationale: Wet breath sounds indicate mucus accumulation in the tracheostomy, necessitating suctioning to clear the airway.
You may also like to solve these questions
Which statement indicates the client diagnosed with asthma needs more teaching concerning the medication regimen?
- A. I will take Singulair, a leukotriene, every day to prevent allergic asthma attacks.
- B. I need to use my Intal, cromolyn inhaler, 15 minutes before I begin my exercise.
- C. I need to take oral glucocorticoids every day to prevent my asthma attacks.
- D. If I have an asthma attack, I need to use my albuterol, a beta2 agonist, inhaler.
Correct Answer: C
Rationale: Daily oral glucocorticoids (C) are not typically used for asthma maintenance due to significant side effects; they are reserved for severe exacerbations or specific cases. Inhaled corticosteroids or leukotriene modifiers (like Singulair, A) are preferred for long-term control. Using cromolyn before exercise (B) is correct to prevent exercise-induced bronchospasm. Albuterol for acute attacks (D) is appropriate as a rescue inhaler.
The charge nurse on a surgical floor is making assignments. Which client should be assigned to the most experienced registered nurse (RN)?
- A. The 36-year-old client who has undergone an antral irrigation for sinusitis yesterday and has moderate pain.
- B. The six-(6)-year-old client scheduled for a tonsillectomy and adenoidectomy this morning who will not swallow medication.
- C. The 18-year-old client who had a Caldwell-Luc procedure three (3) days ago and has purulent drainage on the drip pad.
- D. The 45-year-old client diagnosed with a peritonsillar abscess who requires IVPB antibiotic therapy four (4) times a day.
Correct Answer: C
Rationale: Purulent drainage post-Caldwell-Luc (C) suggests infection, requiring experienced assessment. Antral irrigation (A), tonsillectomy refusal (B), and antibiotics (D) are less complex.
The nurse is caring for a client diagnosed with a cold. Which is an example of an alternative therapy?
- A. Vitamin C, 2,000 mg daily.
- B. Strict bedrest.
- C. Humidification of the air.
- D. Decongestant therapy.
Correct Answer: A
Rationale: Vitamin C (A) is an alternative therapy for colds, with unproven efficacy. Bedrest (B), humidification (C), and decongestants (D) are standard supportive measures.
The client has been diagnosed with chronic sinusitis. Which sign/symptom alerts the nurse to a potentially life-threatening complication?
- A. Muscle weakness.
- B. Purulent sputum.
- C. Nuchal rigidity.
- D. Intermittent loss of muscle control.
Correct Answer: C
Rationale: Nuchal rigidity (C) suggests meningitis, a life-threatening sinusitis complication. Muscle weakness (A) and loss of control (D) are unrelated, and purulent sputum (B) is more typical of respiratory infections.
The client diagnosed with tuberculosis has been treated with antitubercular medications for six (6) weeks. Which data would indicate the medications have been effective?
- A. A decrease in the white blood cells in the sputum.
- B. The client's symptoms are improving.
- C. No change in the chest X-ray.
- D. The skin test is now negative.
Correct Answer: B
Rationale: Improved symptoms (B) after six weeks of TB treatment (e.g., reduced cough, fever) indicate medication efficacy. WBCs in sputum (A) are not a standard measure. Chest X-ray changes (C) lag behind clinical improvement. The skin test (D) remains positive post-exposure, regardless of treatment.