Nokea
While the nurse is suctioning a tracheostomy tube, the client starts to cough. What is the best action for the nurse to take?
- A. Suction deeper to pick up secretions
- B. Gently withdraw suction tubing to allow suction or coughing out of mucus
- C. Remove the suction as quickly as possible
- D. Put the suction tube in and out several times to pick up secretions
Correct Answer: C
Rationale: Removing the suction quickly allows the client to cough out mucus naturally, preventing irritation or trauma.
You may also like to solve these questions
The nurse is writing a care plan for a client newly diagnosed with cancer of the larynx. Which problem is the highest priority?
- A. Wound infection.
- B. Hemorrhage.
- C. Respiratory distress.
- D. Knowledge deficit.
Correct Answer: C
Rationale: Respiratory distress (C) is life-threatening post-laryngectomy, a priority. Infection (A), hemorrhage (B), and knowledge deficit (D) are secondary.
The client diagnosed with chronic sinusitis who has undergone a Caldwell-Luc procedure is complaining of pain. Which intervention should the nurse implement first?
- A. Administer the narcotic analgesic intravenous push (IVP).
- B. Perform gentle oral hygiene.
- C. Place the client in semi-Fowler's position.
- D. Assess the client's pain.
Correct Answer: D
Rationale: Pain assessment (D) is the first step to determine severity and guide treatment. Narcotics (A), oral hygiene (B), and positioning (C) follow based on assessment.
The client diagnosed with oat cell carcinoma of the lung tells the nurse, 'I am so tired of all this. I might as well just end it all.' Which statement should be the nurse's first response?
- A. Say, 'This must be hard for you. Would you like to talk?'
- B. Tell the HCP of the client's statement.
- C. Refer the client to a social worker or spiritual advisor.
- D. Find out if the client has a plan to carry out suicide.
Correct Answer: A
Rationale: Acknowledging feelings and offering to talk (A) opens communication for suicidal ideation. Notifying HCP (B), referring (C), and assessing plans (D) follow.
The client diagnosed with a pulmonary embolus is in the intensive care department. Which assessment data warrant immediate intervention from the nurse?
- A. The client's ABGs are pH 7.36, Pao2 95, Paco2 38, Hco3 24.
- B. The client's telemetry exhibits occasional premature ventricular contractions (PVCs).
- C. The client's pulse oximeter reading is 90%.
- D. The client's urinary output for the 12-hour shift is 800 mL.
Correct Answer: C
Rationale: SpO2 90% (C) indicates hypoxia in PE, requiring immediate oxygen adjustment. Normal ABGs (A), occasional PVCs (B), and urine output (D) are less urgent.
The case manager is arranging a care planning meeting regarding the care of a 65-year-old client diagnosed with adult-onset asthma. Which health-care disciplines should participate in the meeting? Select all that apply.
- A. Nursing.
- B. Pharmacy.
- C. Social work.
- D. Occupational therapy.
- E. Speech therapy.
Correct Answer: A,B,C
Rationale: Nursing (A), pharmacy (B), and social work (C) address asthma management, medications, and social needs. Occupational (D) and speech (E) therapies are less relevant.