Nokea
Wilma was shocked to see that the Tracheostomy was dislodged. Both the inner and outer cannulas was removed and left hanging on James’ neck. What are the 2 equipment’s at james’ bedside that could help Wilma deal with this situation?
- A. New set of tracheostomy tubes and Oxygen tank
- B. Theophylline and Epinephrine
- C. Obturator and Kelly clamp
- D. Sterile saline dressing
Correct Answer: A
Rationale: The correct answer is A: New set of tracheostomy tubes and Oxygen tank.
Rationale:
1. New set of tracheostomy tubes: Essential for reinserting the cannulas to secure the airway.
2. Oxygen tank: To ensure James has a stable oxygen supply while the tracheostomy tubes are being reinserted.
Summary of incorrect choices:
B: Theophylline and Epinephrine - These medications are not directly related to managing a dislodged tracheostomy.
C: Obturator and Kelly clamp - While these are useful tools for tracheostomy care, they are not the immediate equipment needed in this emergency situation.
D: Sterile saline dressing - This is not relevant for a dislodged tracheostomy; the priority is securing the airway.
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A patient recovering from a leg fracture after a fall reports having dull pain in the affected leg and rates it as a 7 on a 0 to 10 scale. The patient is not able to walk around in the room with crutches because of leg discomfort. Which nursing intervention is priority?
- A. Assist the patient to walk in the room with crutches.
- B. Obtain a walker for the patient.
- C. Consult physical therapy.
- D. Administer pain medication.
Correct Answer: D
Rationale: The correct answer is D: Administer pain medication. The priority in this situation is to address the patient's pain and provide relief. Administering pain medication will help alleviate the discomfort and enable the patient to mobilize with crutches or a walker. Walking without pain is crucial for the patient's recovery.
Explanation for other choices:
A: Assisting the patient to walk with crutches may worsen the pain and should not be attempted until the pain is managed.
B: Obtaining a walker is not the priority as the immediate concern is addressing the patient's pain.
C: Consulting physical therapy may be beneficial in the long term, but immediate pain relief is the priority in this situation.
A charge nurse is reviewing outcome statements using the SMART approach. Which patient outcome statement will the charge nurse praise to the new nurse?
- A. The patient will ambulate in hallways.
- B. The nurse will monitor the patient’s heart rhythm continuously this shift. The patient will feed self at all mealtimes today without reports of shortness of
- C. breath. The nurse will administer pain medication every 4 hours to keep the patient free from
- D. discomfort.
Correct Answer: B
Rationale: The correct answer is B because it follows the SMART approach: Specific (monitor heart rhythm), Measurable (continuously this shift), Achievable (feed self at all mealtimes), Relevant (shortness of breath), and Time-bound (today). Choice A lacks specificity and measurability. Choice C focuses on the nurse's action, not patient outcomes. Choice D lacks specificity and measurability, focusing on the nurse's actions rather than patient outcomes.
The following would be a symptom the nurse would expect to find during assessment of a patient with macular degeneration, EXCEPT:
- A. Decreased ability to distinguish colors
- B. Loss of central vision
- C. Loss of near vision
- D. Loss of peripheral vision
Correct Answer: D
Rationale: The correct answer is D: Loss of peripheral vision. Macular degeneration affects the central vision, specifically the macula, which is responsible for central vision and sharp detail. Loss of peripheral vision is not a typical symptom of macular degeneration. The macula is located in the center of the retina, so symptoms would relate to central vision impairments such as decreased ability to distinguish colors, loss of central vision, and loss of near vision. Peripheral vision is not primarily affected by macular degeneration, hence it is not an expected symptom.
A client with newly diagnosed type 2 diabetes mellitus is admitted to the metabolic unit. The primary goal for this admission is education. Which of the following goals should the nurse incorporate into her teaching plan?
- A. Maintenance of blood glucose levels between 180 and 200mg/dl
- B. Smoking reduction but not complete cessation
- C. An eye examination every 2 years until age 50
- D. Exercise and a weight reduction diet
Correct Answer: D
Rationale: The correct answer is D, as exercise and a weight reduction diet are essential components in managing type 2 diabetes. Exercise helps lower blood glucose levels and improves insulin sensitivity. Weight reduction reduces insulin resistance. Choice A is incorrect because maintaining blood glucose levels between 180-200mg/dl is too high and can lead to complications. Choice B is incorrect as complete smoking cessation is crucial for overall health and diabetes management. Choice C is incorrect because eye examinations should be done annually, not every 2 years, to monitor for diabetic retinopathy. In summary, choice D is the best option as it directly addresses the management of type 2 diabetes.
Appropriate nursing interventions for J.E. would be
- A. Skin care and position q2h and prn; maintain alignment of extremities; respiratory exercises
- B. Skin care/bathe daily; passive leg exercises daily; respiratory therapy for intermittent positive pressure breathing therapy
- C. Skin care and position q2h; teach use of overhead trapeze; respiratory exercises, and intermittent positive pressure breathing q2h
- D. Skin care q2h; teach use of overhead trapeze; respiratory exercises; use pressure relief devices Situation - Mr. Reyes suffered head injuries in a motor vehicle accident
Correct Answer: A
Rationale: The correct answer is A because it includes essential nursing interventions for a patient with head injuries like J.E. Skin care and position changes every 2 hours help prevent pressure ulcers. Maintaining alignment of extremities prevents contractures. Respiratory exercises aid in lung function. Option B lacks the crucial aspect of maintaining extremity alignment. Option C includes teaching the use of an overhead trapeze, which may not be appropriate for J.E. Option D lacks the instruction to maintain extremity alignment, which is crucial for preventing contractures in patients with head injuries.