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Which one of the following assessments is most appropriate for determining the correct placement of an endotracheal tube in a mechanically ventilated client?
- A. Assessing the client's skin color.
- B. Abrupting the respiratory rate.
- C. Verifying the amount of cuff inflation.
- D. Auscultating breath sounds bilaterally.
Correct Answer: D
Rationale: Auscultating bilateral breath sounds confirms correct endotracheal tube placement in both lungs. Skin color, respiratory rate, and cuff inflation are less specific.
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The nurse is planning a home visit for a client with hepatitis. In order to prevent transmission the nurse should focus teaching on:
- A. Proper food handling.
- B. Insulin syringe disposal.
- C. Alpha-interferon.
- D. Use of condoms.
Correct Answer: D
Rationale: Hepatitis B and C are transmitted via body fluids, so condom use (D) prevents sexual transmission. Food handling (A) is key for hepatitis A, syringe disposal (B) applies to needle-sharing, and alpha-interferon (C) is a treatment, not a preventive measure.
While changing the client's colostomy bag and dressing, the nurse assesses that the client is ready to participate in her care by noting which of the following?
- A. The client asks what time the doctor will visit that day.
- B. The client asks about the supplies used during the dressing change.
- C. The client talks about something she read in the morning newspaper.
- D. The client complains about the way the night nurse changed the dressing.
Correct Answer: B
Rationale: The client's inquiry about the supplies used during the dressing change indicates interest and readiness to participate in her colostomy care. Other options reflect unrelated concerns or dissatisfaction, not readiness to engage in self-care. CN: Psychosocial adaptation; CL: Evaluate
The client has midcalf pain when walking a block or more. The client states that the discomfort is relieved with rest. The pain is expected when arterial occlusion reaches which of the following percentages?
- A. 20%
- B. 40%
- C. 50%
- D. 100%
Correct Answer: C
Rationale: Claudication typically occurs when arterial occlusion reaches approximately 50%, significantly reducing blood flow to muscles during activity. This causes ischemia and pain, which is relieved by rest when oxygen demand decreases. Complete (100%) occlusion would cause rest pain or tissue necrosis, not just claudication.
The nurse is reviewing laboratory reports for a client who is taking allopurinol (Zyloprim). Which of the following indicate that the drug has had a therapeutic effect?
- A. Decreased urine alkaline phosphatase level.
- B. Increased urine calcium excretion.
- C. Increased serum calcium level.
- D. Decreased serum uric acid level.
Correct Answer: D
Rationale: Allopurinol reduces serum uric acid levels, indicating therapeutic effectiveness in preventing uric acid stone formation.
The nurse in the intensive care unit is giving a report to the nurse in a cardiac step-down unit about a client who had coronary artery bypass surgery. Which of the following is the most effective way to assure essential information about the client is reported?
- A. Give the report face-to-face with both nurses in a quiet room.
- B. Audiotape the report for future reference and documentation.
- C. Use a printed checklist with information individualized for the client.
- D. Document essential transfer information in the client's electronic health record.
Correct Answer: C
Rationale: A printed checklist individualized for the client ensures all essential information is systematically communicated, reducing errors during handoff.