Kaplan NCLEX Readiness Exam
Terms in this set (180)
The nurse cares for a client
with a cuffed tracheostomy
tube. Before performing oral
care, the
... [Show More] nurse notes that the
client's tracheostomy cuff is
inflated. Which of the following
is the MOST appropriate action
for the nurse to take?
before suctioning.
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 Hg2/139
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) Implementatio
n: 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;
increasesthe risk of trauma to lower airways3/139
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;
MOSTappropriate? 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
using nicotine polacrilex
appropriate; can be asked as part of assessment
(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?"
2. "How long have you been
of nicotine is vasoconstriction; increases heart rate
and myocardial oxygen consumption; increased risk
smoking?" of angina and myocardial infarction
3. "Have you ever had chest
pain?" 4) Assessment: outcome may be appropriate but
4. "Do you have a partial dental not priority; gum is place between cheek and gums;
bridge?" may stain dental work4/139
The nurse cares for the client
with a client controlled
analgesia (PCA) pump. The
and received 6 doses of
morphine during the last hour.
Which is the MOST appropriate
appropriate; if tubing is obstructed, alarm is
activated
2) Assessment: outcome may be appropriate but
description of the pain, region and radiation of the
PCA IV tubing.
Determine the client's
understanding of the PCA
pump function.
Ask the client to describe the [Show Less]