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 nurse at a long-term care facility is part of a team preparing a report on the quality of care at the facility. Which of the following information should the nurse recommend including in the report to demonstrate improvement in care quality?
- A. Increased admissions
- B. 12% fewer urinary tract infections
- C. Increased mortality rate
- D. No changes in staffing
Correct Answer: B
Rationale: The correct answer is B: '12% fewer urinary tract infections.' Tracking infections, such as UTIs, is crucial in assessing care quality improvements as the reduction in infections indicates better infection control practices and overall quality of care. Choices A, C, and D are incorrect. Increased admissions (Choice A) do not directly reflect improvements in care quality. Increased mortality rate (Choice C) is a negative outcome and demonstrates a decline in care quality. No changes in staffing (Choice D) do not provide direct evidence of care quality improvements.
A client who is at 38 weeks of gestation and has a history of hepatitis C asks the nurse if she will be able to breastfeed. Which of the following responses by the nurse is appropriate?
- A. You may breastfeed unless your nipples are cracked or bleeding.
- B. You must use a breast pump to provide breast milk.
- C. You must use a nipple shield when breastfeeding.
- D. You may breastfeed after your baby develops antibodies.
Correct Answer: A
Rationale: The correct response is A: 'You may breastfeed unless your nipples are cracked or bleeding.' In the case of hepatitis C, breastfeeding is generally safe unless the mother's nipples are cracked or bleeding, which could increase the risk of transmission to the baby. Choice B is incorrect as using a breast pump is not a mandatory requirement for breastfeeding with hepatitis C. Choice C is incorrect as a nipple shield is not necessary in this situation. Choice D is incorrect because the baby developing antibodies does not impact the decision to breastfeed in the context of hepatitis C.
What is the most appropriate response when a client with chronic kidney disease asks about fluid restrictions?
- A. Fluid restrictions are not needed for all clients with chronic kidney disease.
- B. You may need to limit fluid intake to prevent fluid overload.
- C. Fluid restrictions are based on your lab results and daily weights.
- D. Restricting fluids is only necessary during dialysis.
Correct Answer: B
Rationale: The most appropriate response when a client with chronic kidney disease asks about fluid restrictions is to inform them that limiting fluid intake may be necessary to prevent fluid overload. This is crucial in managing the condition and preventing complications such as edema and electrolyte imbalances. Choice A is incorrect as fluid restrictions are commonly advised for clients with chronic kidney disease. Choice C is partially correct as fluid restrictions are indeed based on lab results and daily weights, but the primary goal is to prevent fluid overload. Choice D is incorrect because fluid restrictions are not limited to just during dialysis; they are often recommended throughout the day to manage the condition.
What are the key differences between viral and bacterial infections?
- A. Viral infections typically last longer than bacterial infections.
- B. Bacterial infections typically cause high fever.
- C. Both bacterial and viral infections cause rashes.
- D. Viral infections cause sudden onset of symptoms.
Correct Answer: A
Rationale: The correct answer is A. Viral infections typically last longer than bacterial infections. This is because viral infections often require the body's immune system to fight off the virus, leading to a longer duration of illness. Bacterial infections, on the other hand, often cause a rapid onset of symptoms due to the toxins produced by bacteria. Choice B is incorrect because not all bacterial infections cause high fever. Choice C is incorrect because rashes can be caused by both bacterial and viral infections, but not always. Choice D is incorrect because while some viral infections may cause a sudden onset of symptoms, it is not a key distinguishing factor between viral and bacterial infections.
A nurse is reviewing the plan of care for a client who is receiving total parenteral nutrition (TPN). Which of the following interventions should the nurse include?
- A. Monitor daily fluid intake
- B. Monitor blood glucose levels
- C. Measure intake and output
- D. Administer insulin as prescribed
Correct Answer: B
Rationale: The correct answer is B: 'Monitor blood glucose levels.' When a client is receiving total parenteral nutrition (TPN), which has a high glucose content, it is crucial to monitor blood glucose levels closely to prevent hyperglycemia. Monitoring daily fluid intake (Choice A) is important in other contexts but is not directly related to TPN administration. Measuring intake and output (Choice C) is a general nursing intervention that is relevant for assessing fluid balance but is not specific to TPN administration. Administering insulin as prescribed (Choice D) may be necessary for clients with hyperglycemia, but this intervention is based on the blood glucose monitoring results and the healthcare provider's orders, not a standard intervention for all clients receiving TPN.