Nokea
Which observation by the nurse indicates a need to suction a client with an endotracheal (ET) tube attached to a mechanical ventilator? Select all that apply.
- A. Audible crackles
- B. Client notably restless
- C. Visible mucus bubbling in the ET tube
- D. Apical pulse rate of 72 beats per minute
- E. Low peak inspiratory pressure on the ventilator
- F. High alarm pressures identified by the ventilator
Correct Answer: A,B,C,F
Rationale: Indications for suctioning include visible mucus bubbling in the ET tube, wet respirations, restlessness, rhonchi or crackles on auscultation of the lungs, increased pulse and respiratory rates, and increased peak inspiratory pressures on the ventilator and high-pressure alarms on the ventilator. A low peak inspiratory pressure indicates a leak in the mechanical ventilation system.
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The nurse has completed tracheostomy care for a client whose tracheostomy tube has a nondisposable inner cannula. Which intervention will the nurse implement immediately before reinserting the inner cannula?
- A. Rinsing it in sterile water
- B. Suctioning the client's airway
- C. Tapping it gently against a sterile basin
- D. Drying it with the provided pipe cleaners
Correct Answer: D
Rationale: After washing and rinsing the inner cannula, the nurse taps it dry to remove large water droplets and then uses pipe cleaners specifically for use with a tracheostomy to dry it; then the nurse inserts the cannula into the tracheostomy and turns it clockwise to lock it into place. The nurse should avoid shaking or tapping the inner cannula to prevent contamination. A wet cannula should not be inserted into a tracheostomy because water is a lung irritant.
The nurse prepares the client for the removal of a nasogastric tube. During the tube removal, the nurse instructs the client to take which action?
- A. Inhale deeply.
- B. Exhale slowly.
- C. Hold in a deep breath.
- D. Pause between breaths.
Correct Answer: C
Rationale: Just before removing the tube, the client is asked to take a deep breath and hold it because breath-holding minimizes the risk of aspirating gastric contents spilled from the tube during removal. The maneuver partially occludes the airway during tube removal; afterward, the client exhales as soon as the tube is out and thus avoids drawing the gastric contents into the trachea.
The nurse is preparing to administer eardrops to an infant. The nurse should plan to proceed by taking which step to assure the appropriate instillation of the medication?
- A. Pull down and back on the auricle, and direct the solution onto the eardrum.
- B. Pull up and back on the earlobe, and direct the solution toward the wall of the ear canal.
- C. Pull up and back on the auricle, and direct the solution toward the wall of the ear canal.
- D. Pull down and back on the auricle, and direct the solution toward the wall of the ear canal.
Correct Answer: D
Rationale: The infant should be turned on the side with the affected ear uppermost. With the nondominant hand, the nurse pulls down and back on the auricle. The wrist of the dominant hand is rested on the infant's head. The medication is administered by aiming it at the wall of the ear canal rather than directly onto the eardrum. The infant should be held or positioned with the affected ear uppermost for 10 to 15 minutes to retain the solution. In the adult, the auricle is pulled up and back to straighten the auditory canal.
The nurse is providing care for a client who has just experienced a liver biopsy performed at the bedside. Which position should the nurse place the client in after the biopsy?
- A. Supine with the head elevated on one pillow
- B. Semi-Fowler's with two pillows under the legs
- C. Left side-lying with a small pillow under the puncture site
- D. Right side-lying with a folded towel under the puncture site
Correct Answer: D
Rationale: The liver is located on the right side of the body. After a liver biopsy, the nurse positions the client on the right side with a small pillow or folded towel under the puncture site for 2 hours. This position compresses the liver against the abdominal wall at the biopsy site to tamponade bleeding from the puncture site.
A prenatal client is being evaluated for possible gestational diabetes. Which data identified and documented after the client's initial nursing assessment would support that diagnosis?
- A. 22 years old
- B. A gravida 4, para 0, aborta 3
- C. 5^{\prime} 6^{\prime \prime tall, weighs 130 pounds
- D. Stated, 'I get really tired after working all day'
Correct Answer: B
Rationale: A history of unexplained stillbirths or miscarriages puts the client at high risk for gestational diabetes. Fatigue is a normal occurrence during pregnancy. The client's height (5'6†tall) and weight (130 pounds) do not meet the criteria of 20% over ideal weight. Therefore, the client is not obese, a possible factor related to gestational diabetes. To be at high risk for gestational diabetes, the maternal age should be greater than 25 years.