Nokea
Which of the following actions should the nurse take first?
- A. Determine the client's Glasgow Coma Scale score
- B. Insert an indwelling urinary catheter for the client.
- C. Administer mannitol IV bolus to the client
- D. Prepare the client for an MRI of the brain.
Correct Answer: A
Rationale: The correct answer is A: Determine the client's Glasgow Coma Scale (GCS) score. This is the priority action as it helps assess the client's level of consciousness and neurological status quickly. It guides further interventions and treatment decisions. Inserting an indwelling urinary catheter (B) or administering mannitol IV bolus (C) may be needed but assessing neurological status comes first. Preparing for an MRI (D) is important but not the initial step.
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Which of the following interventions should the nurse include?
- A. Assess the child for frequent swallowing
- B. Carefully suction the child's oropharynx to remove secretions
- C. Administer pancreatic enzymes with meals
- D. Continuously monitor the child's respiratory status
Correct Answer: A
Rationale: Frequent swallowing indicates airway obstruction risks.
Which of the following instructions should the nurse include?
- A. Monitor for weight loss
- B. Increase dietary calcium.
- C. Take on an empty stomach.
- D. Schedule dosage at bedtime
Correct Answer: B
Rationale: The correct answer is B: Increase dietary calcium. This instruction is important for a patient likely prescribed with a medication that can deplete calcium levels. Calcium is essential for bone health and overall well-being. Monitoring weight loss (A) is important but not directly related to the medication's side effects. Taking on an empty stomach (C) or at bedtime (D) may be specific to certain medications, but not universally applicable.
Which of the following anterior chest wall locations should the nurse auscultate?(You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
Correct Answer:
Rationale: Correct Answer: D (Second intercostal space, right sternal border)
Rationale: The nurse should auscultate at the second intercostal space, right sternal border to listen to the aortic valve. This location corresponds to the area where the aortic valve can be best heard. The aortic valve is located in the second intercostal space, right sternal border, so auscultating at this spot allows for accurate assessment of the heart sounds in this area. It is essential to auscultate at this specific location to detect any abnormalities or abnormalities in the aortic valve.
Summary of other choices:
- A, B, C, E, F, G: These locations do not correspond to the specific area where the aortic valve is best heard. Auscultating at these locations may not provide clear or accurate heart sounds related to the aortic valve.
A nurse is providing discharge teaching to the partner of a client who has a tracheostomy. Which of the following information should the nurse include in the teaching?
- A. How to operate the portable suction machine
- B. How to secure the tracheostomy tube with ties at the back of the neck
- C. How to change the nondisposable tracheostomy tube daily
- D. How to change the tracheostomy dressing using clean technique
Correct Answer:
Rationale: Correct Answer: B. How to secure the tracheostomy tube with ties at the back of the neck.
Rationale: Securing the tracheostomy tube with ties is crucial to prevent accidental dislodgement and ensure proper placement for oxygenation. This step helps maintain the airway and prevents complications. Teaching this ensures safety and proper care for the client.
Incorrect Choices:
A: Operating the portable suction machine is important but not the priority for discharge teaching.
C: Changing the nondisposable tracheostomy tube daily is not recommended as it can increase the risk of infection.
D: Changing the tracheostomy dressing using clean technique is essential, but securing the tube takes precedence in discharge teaching.
Which of the following findings require follow up? Select all that apply.
- A. WBC count
- B. Temperature
- C. Potassium level
- D. Breath sounds
- E. Blood pressure
Correct Answer: A,B,D,E
Rationale: These findings suggest infection and respiratory distress, requiring immediate follow-up.