Nokea
You are supervising a student nurse who is performing tracheostomy care for a client. For which action should you intervene?
- A. The student nurse suctions the tracheostomy tube prior to performing tracheostomy care.
- B. The student nurse removes old dressings and cleans off excess secretions.
- C. The student nurse removes the inner cannula and cleans using universal precautions.
- D. The student nurse replaces the inner cannula and cleans the stoma site.
Correct Answer: A
Rationale: The correct answer is A. Suctioning prior to tracheostomy care is incorrect because it increases the risk of introducing infection. Removing old dressings and cleaning secretions (B), removing and cleaning the inner cannula (C), and replacing the inner cannula and cleaning the stoma site (D) are standard steps in tracheostomy care.
You may also like to solve these questions
A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of water. Which action should the nurse take next?
- A. Call the physician and request a prescription for food and water.
- B. Provide the client with ice chips instead of a drink of water.
- C. Assess the client's gag reflex before giving any food or water.
- D. Let the client have a small sip to see whether he or she can swallow.
Correct Answer: C
Rationale: Correct Answer: C
Rationale:
1. Assessing the client's gag reflex is crucial after a bronchoscopy to prevent aspiration.
2. Gag reflex helps protect the airway from foreign substances entering the lungs.
3. Providing food or water without assessing the gag reflex can lead to aspiration pneumonia.
4. It is essential to ensure the client's safety before allowing any intake post-bronchoscopy.
Summary:
A: Calling the physician for a prescription is not necessary at this immediate stage.
B: Ice chips may still pose a risk if the client cannot protect their airway.
D: Allowing a sip without assessing gag reflex may lead to aspiration.
Pneumotaxic center is
- A. Inhibitory
- B. Accelatory
- C. Activating
- D. None of these
Correct Answer: A
Rationale: The correct answer is A: Inhibitory. The pneumotaxic center is located in the upper pons and functions to inhibit inspiration, preventing overinflation of the lungs. This helps regulate the respiratory rate and depth. The other choices are incorrect because the pneumotaxic center does not accelerate or activate breathing directly. It exerts its influence by inhibiting the inspiratory neurons in the medulla, thereby controlling the duration and frequency of inspiration. Choice D is incorrect as the pneumotaxic center does have a specific inhibitory function in the respiratory control system.
A nurse is preparing to obtain a sputum specimen from a male client. Which of the following nursing actions will facilitate obtaining the specimen?
- A. Limiting fluid.
- B. Having the client take deep breaths.
- C. Asking the client to spit into the collection container.
- D. Asking the client to obtain the specimen after eating.
Correct Answer: B
Rationale: The correct answer is B: Having the client take deep breaths. This action facilitates obtaining a sputum specimen by helping the client to cough and expectorate sputum effectively. Deep breaths help to mobilize secretions, making it easier for the client to produce a quality specimen. Limiting fluid intake (choice A) can lead to dehydration and thickening of secretions, making it harder to obtain a specimen. Asking the client to spit into the container (choice C) may result in contamination with saliva. Asking the client to obtain the specimen after eating (choice D) can introduce food particles into the specimen, affecting the accuracy of the test.
A nursing instructor asks a nursing student to describe the route of transmission of tuberculosis. The instructor concludes that the student understands this information if the student states that tuberculosis is transmitted by:
- A. Hand to mouth
- B. The airborne route
- C. The fecal-oral route
- D. Blood and body fluids
Correct Answer: B
Rationale: The correct answer is B: The airborne route. Tuberculosis is primarily transmitted through the air when an infected person coughs or sneezes, releasing droplets containing the TB bacteria. These droplets can be inhaled by others, leading to the transmission of the disease. This mode of transmission is supported by scientific evidence and is well-documented in medical literature.
Choice A (Hand to mouth) is incorrect because TB is not typically transmitted through direct contact with contaminated hands to mouth. Choice C (The fecal-oral route) is incorrect as TB is not transmitted through fecal-oral route but primarily through respiratory droplets. Choice D (Blood and body fluids) is incorrect as TB is not commonly transmitted through blood or body fluids, but rather through respiratory droplets in the air.
A male adult patient on mechanical ventilation is receiving pancuronium bromide (Pavulon), 0.01 mg/kg I.V. as needed. Which assessment finding indicates that the patient needs another pancuronium dose?
- A. Leg movement
- B. Finger movement
- C. Lip movement
- D. Fighting the ventilator
Correct Answer: D
Rationale: The correct answer is D: Fighting the ventilator. This indicates inadequate muscle relaxation, requiring another dose of pancuronium. Leg, finger, and lip movements are not reliable indicators of muscle relaxation in a mechanically ventilated patient. Fighting the ventilator suggests the patient is not adequately sedated or paralyzed, requiring further intervention to maintain optimal ventilation and oxygenation.