Nokea
Which of the following is an early indicator that suctioning is needed for a client with a tracheostomy?
- A. Bradycardia
- B. Hypotension
- C. Irritability
- D. Confusion
Correct Answer: C
Rationale: Irritability is an early indicator that suctioning is needed for a client with a tracheostomy because it can signal discomfort or difficulty breathing due to mucus accumulation, prompting the need for suctioning to clear the airway. Bradycardia (Choice A) and hypotension (Choice B) are not typically early indicators of the need for suctioning in a client with a tracheostomy. Confusion (Choice D) is also not a direct early indicator of the need for suctioning in this context.
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A client with a tracheostomy is exhibiting signs of respiratory distress. What is the nurse's immediate priority?
- A. Increase the oxygen flow rate
- B. Suction the tracheostomy
- C. Notify the physician immediately
- D. Administer a bronchodilator
Correct Answer: B
Rationale: When a client with a tracheostomy is experiencing respiratory distress, the immediate priority for the nurse is to suction the tracheostomy. This action helps clear the airway of secretions and ensures that the client can breathe effectively. Increasing the oxygen flow rate may be necessary but addressing the airway obstruction is more critical. Notifying the physician immediately is important but may cause a delay in addressing the immediate need for airway clearance. Administering a bronchodilator may help with bronchospasm but should not take precedence over ensuring a clear airway in a client with respiratory distress.
A client with a serum albumin level of 3 g/dL has a pressure ulcer. What should the nurse do first?
- A. Monitor the client's fluid and electrolyte balance
- B. Consult a dietitian to improve the client's nutritional status
- C. Administer a protein supplement
- D. Administer an anti-inflammatory medication
Correct Answer: B
Rationale: The correct first action for a client with a serum albumin level of 3 g/dL and a pressure ulcer is to consult a dietitian to improve the client's nutritional status. Adequate nutrition is essential for wound healing. Monitoring fluid and electrolyte balance is important but not the first priority in this situation. Administering a protein supplement can be considered after dietary evaluation. Administering an anti-inflammatory medication is not the primary intervention for addressing a pressure ulcer related to low albumin levels.
What is the correct intervention for a patient experiencing anaphylaxis?
- A. Administer epinephrine
- B. Provide oxygen
- C. Monitor airway
- D. All of the above
Correct Answer: D
Rationale: In cases of anaphylaxis, all of the listed interventions are crucial for effective management. Administering epinephrine is the primary treatment to reverse the allergic reaction rapidly. Providing oxygen ensures adequate oxygenation to vital organs, and monitoring the airway is essential to prevent obstruction and maintain a clear air passage. Therefore, all three interventions are necessary in managing anaphylaxis. Choices A, B, and C are not individually sufficient to address all aspects of anaphylaxis, making the comprehensive approach of 'All of the above' the correct answer.
What are the signs and symptoms of opioid withdrawal, and how should they be managed?
- A. Nausea, sweating, and increased heart rate; manage with methadone
- B. Pain and restlessness; manage with naloxone
- C. Hallucinations and muscle cramps; manage with clonidine
- D. Severe vomiting and seizures; manage with benzodiazepines
Correct Answer: A
Rationale: The signs and symptoms of opioid withdrawal include nausea, sweating, and increased heart rate. Methadone is commonly used to manage opioid withdrawal symptoms by alleviating them. Choice B, managing with naloxone, is incorrect as naloxone is primarily used for opioid overdose reversal, not withdrawal. Choice C, managing with clonidine, is incorrect as clonidine is used to manage some symptoms of withdrawal, such as anxiety, agitation, and hypertension, but not hallucinations. Choice D, managing with benzodiazepines, is incorrect as benzodiazepines are not typically used as first-line treatment for opioid withdrawal; they may be considered in specific cases but are not a standard approach.
A nurse is reinforcing discharge teaching about car seat safety with the guardian of a newborn. Which of the following statements by the guardian indicates an understanding of the teaching?
- A. I will position the car seat in the front seat
- B. I will secure the car seat in the car by using the seatbelt
- C. I will use a rear-facing car seat
- D. I will install the car seat facing forward
Correct Answer: C
Rationale: The correct answer is C. Using a rear-facing car seat is the safest position for a newborn. Newborns should always be placed in a rear-facing car seat in the back seat of the vehicle to provide optimal safety in case of a crash. Choice A is incorrect because placing the car seat in the front seat is not safe due to the presence of airbags. Choice B is incorrect as securing the car seat using the seatbelt is not specific to the correct positioning of the car seat. Choice D is incorrect because installing the car seat facing forward is not recommended for newborns as it does not provide the same level of protection as a rear-facing position.