KAPLAN NCLEX READINESS EXAM 100+ QUESTIONS
WITH UPDATED VERIFIED SOLUTIONS/2023/A+ GRADE
The nurse cares for a client
with a cuffed
... [Show More] tracheostomy
tube. Before performing oral
care, the nurse notes that the
client's tracheostomy cuff is
inflated. Which of the following
is the MOST appropriate action
for the nurse to take?
1. Leave the cuff inflated and
suction through the
tracheostomy.
2. Deflate the cuff and suction
through the tracheostomy
tube.
3. Inflate the cuff pressure to
40 mm Hg before suctioning.
4. Adjust the wall suction
pressure to 160 to 180 mm Hg
before suctioning.
1) CORRECT - Implementation: outcome desired;
cuff inflation decreases the risk of aspiration; cuff
position and pressure should be assessed
frequently; swallowing and breathing will cause
tracheostomy tube movement
2) Implementation: outcome not desired;
accumulated oral secretions above the cuff will
drain into the bronchi; increased risk of infection
3) Implementation: outcome not desired; cuff
pressure should be less than 20 mm Hg (25 cm
H2O); risk of trauma to trachea with higher
pressures
4) Implementation: outcome not desired; increases
the risk of trauma to lower airways
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2
A young adult brings a friend 1) Assessment: outcome not priority but may be
to the emergency department appropriate; pinpoint pupils are a sign of heroin
and states that the friend has overdose
been using heroin. Which
action by the nurse is the 2) CORRECT - Assessment: outcome priority;
MOST appropriate? shallow respirations seen; impaired alveolar gas
exchange and possible respiratory arrest
1. Assess pupil size and
reactivity. 3) Assessment: outcome not priority; most
2. Assess oxygen saturation important to assess airway and breathing
levels.
3. Palpate dorsalis pedis 4) Assessment: outcome not priority but may be
pulses. appropriate; drowsiness and euphoria may be seen;
4. Ask the client if he knows not priority
today's date.
The client tells the clinic nurse 1) Assessment: outcome not priority but may be
that the client is thinking about appropriate; can be asked as part of assessment
using nicotine polacrilex
(Nicorette). Which question is 2) Assessment: outcome not priority but may be
MOST important for the nurse appropriate; should be assessed for further
to ask? teaching
1. "Have you tried other 3) CORRECT - Assessment: outcome priority; action
methods to stop smoking?" of nicotine is vasoconstriction; increases heart rate
2. "How long have you been and myocardial oxygen consumptio [Show Less]