Nokea
Which nursing action is essential during tracheal suctioning?
- A. Using a lubricant such as petroleum jelly
- B. Administering 100% oxygen before and after suctioning
- C. Making sure the suction catheter is open or on during insertion
- D. Assisting the client to assume a supine position during suctioning
Correct Answer: B
Rationale: Administering 100% oxygen before and after suctioning prevents hypoxia during the procedure.
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Which symptom reported by the client to the nurse is the best indicator that complications are developing from this cold?
- A. Visual stuffiness
- B. Dry cough
- C. High fever
- D. Scratchy throat
Correct Answer: C
Rationale: A high fever suggests a possible secondary bacterial infection or other complication, such as sinusitis or pneumonia, which is more serious than typical cold symptoms.
The nurse is assessing a patient, who has many risk factors for the development of a DVT, for signs and symptoms of a deep vein thrombosis. What signs and symptoms below would possibly indicate a deep vein thrombosis is present?
- A. Cool extremity
- B. Decreases pulses
- C. Redness
- D. Pain
- E. Warm extremity
- F. Swelling
- G. Cyanosis
Correct Answer: C,D,E,F
Rationale: Signs and symptoms of a DVT include: redness, swelling, warm extremity, pain, positive Homan's Sign, and swelling (which can be unilateral...meaning there is more swelling in one extremity compared to the other).
The nurse is planning the care of a client diagnosed with asthma and has written a problem of 'anxiety.' Which nursing intervention should be implemented?
- A. Remain with the client.
- B. Notify the health-care provider.
- C. Administer an anxiolytic medication.
- D. Encourage the client to drink fluids.
Correct Answer: A
Rationale: Remaining with the client (A) reduces anxiety through presence and reassurance. Notification (B), anxiolytics (C), and fluids (D) are secondary or unrelated.
When the client asks the nurse about why the physician has prescribed two drugs, which response is most accurate?
- A. One medication diminishes the side effects of the other.
- B. One medication kills the live organism; the other, its spores.
- C. Using combined medications can reduce the dosages of both drugs.
- D. Using two or more drugs lowers the potential for bacterial resistance.
Correct Answer: D
Rationale: Combination therapy (rifampin and isoniazid) reduces the risk of bacterial resistance, ensuring effective tuberculosis treatment.
Select all the correct options that represent the pathophysiology of an asthma attack.
- A. The smooth muscle surrounding the alveoli constricts, limiting oxygenation.
- B. The mucosa lining experiences severe inflammation.
- C. The goblet cells within the mucosa lining produce excessive amounts of mucous.
- D. Too much carbon dioxide is exhaled due to hyperventilation and the patient experiences respiratory alkalosis.
Correct Answer: B,C
Rationale: Asthma involves inflammation of the airway mucosa and excessive mucus production by goblet cells. Smooth muscle constriction occurs in bronchioles, not alveoli, and hyperventilation typically leads to respiratory acidosis due to CO2 retention.