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Which type of endotracheal tube is recommended by the Centers for Disease Control (CDC) for reducing the risk of ventilator-associated pneumonia?
- A. Uncuffed
- B. CASS
- C. Fenestrated
- D. Nasotracheal
Correct Answer: B
Rationale: CASS (continuous aspiration of subglottic secretions) tubes reduce ventilator-associated pneumonia by removing secretions.
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The nurse is caring for the patient following removal of a large posterior oral lesion. The priority nursing measure would be to:
- A. Maintain a patent airway
- B. Perform meticulous oral care every 2 hours
- C. Ensure that the incisional area is kept as dry as possible
- D. Assess the client frequently for pain
Correct Answer: A
Rationale: Maintaining a patent airway is critical post-oral surgery due to the risk of swelling or bleeding obstructing the airway.
The school nurse assessed and referred a 14-year-old with scoliosis. An 18° curvature of the spine was diagnosed. Which treatment plan would the nurse expect?
- A. Application of a Milwaukee brace
- B. Electrical stimulation to the outward side of the curve
- C. Re-evaluation, with no treatment at this time
- D. Surgical realignment of the spine
Correct Answer: C
Rationale: An 18° scoliosis curvature is mild and typically monitored with re-evaluation, as bracing or surgery is reserved for curvatures >25° or >40°, respectively.
A nurse has delegated care of a client in wrist restraints to a nursing assistant. The nursing assistant should check the skin circulation under the restraints at least
- A. every 15 minutes.
- B. every 30 minutes.
- C. every hour.
- D. every 2 hours.
Correct Answer: C
Rationale: Restraints require circulation checks every 1-2 hours to prevent skin breakdown or neurovascular injury. Hourly checks (C) balance safety and practicality.
A client with cancer is admitted to the oncology unit. Stat lab values reveal Hgb 12.6, WBC 6500, K+ 1.9, uric acid 7.0, Na+ 136, and platelets 178,000. The nurse evaluates that the client is experiencing which of the following?
- A. Hypernatremia
- B. Hypokalemia
- C. Myelosuppression
- D. Leukocytosis
Correct Answer: B
Rationale: A potassium level of 1.9 mEq/L indicates hypokalemia, which is a critical electrolyte imbalance.
A client with mania is unable to finish her dinner. To help her maintain sufficient nourishment, the nurse should:
- A. Serve high-calorie foods she can carry with her
- B. Encourage her appetite by sending out for her favorite foods
- C. Serve her small, attractively arranged portions
- D. Allow her in the unit kitchen for extra food whenever she pleases
Correct Answer: A
Rationale: High-calorie, portable foods accommodate the restlessness and distractibility of mania, ensuring adequate nutrition.