The nurse cares for a client with a cuffed tracheostomy tube. Before performing oral care, the nurse notes that the client's tracheostomy cuff is
... [Show More] 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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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 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 work
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The nurse cares for the client with a client controlled analgesia (PCA) pump. The nurse determines that the client has pressed the button 11 times and received 6 doses of morphine during the last hour. Which is the MOST appropriate action for the nurse to take?
1. Assess the patency of the PCA IV tubing.
2. Determine the client's understanding of the PCA pump function.
3. Obtain an order to begin a PCA infusion of fentanyl.
4. Ask the client to describe the pain.
1) Assessment: outcome not priority but may be appropriate; if tubing is obstructed, alarm is activated
2) Assessment: outcome may be appropriate but not priority; more important to determine pain level, description of the pain, region and radiation of the pain, and relieving factors
3) Implementation: outcome not desired; more important to assess severity of pain and pain relief first
4) CORRECT - Assessment: outcome priority; must validate that client is in pain before implementation
3/139
A pregnant woman receives an
1) Implementation: outcome not desired; no
epidural anesthetic. After increase in venous return
administration of the epidural
anesthetic, the client's blood 2) Implementation: outcome not desired; will
pressure changes from 120/84 decrease venous return
to 94/50. Which action by the
nurse is MOST appropriate? 3) CORRECT - Implementation: outcome desired;
will increase venous return and cardiac output; fetal
1. Place the client flat on her pressure on inferior vena cava reduced
back.
2. Elevate the head of the bed 4) Implementation: outcome not desired; elevation
30 degrees. of legs will increase venous return, but fetal
3. Place the client on her left pressure on vena cava will prevent blood return to
side with her legs flexed. heart
4. Place the client supine with
the foot of the bed elevated.
A nursing order, "Increase fluid
1) CORRECT - Assessment: outcome priority;
intake" is written for a client increased amounts of antidiuretic hormone
diagnosed with dehydration. secreted; urine output decreased and concentrated
Which finding BEST indicates
improving fluid status? 2) Assessment: outcome not priority; indicates that
blood is hemoconcentrated
1. Urinary output of 1,500 mL in
24 hours. 3) Assessment: outcome not priority; normal intake
2. Serum hematocrit 52%. is 1,500 mL in 24 hours
3. Oral fluid intake of 900 mL in
24 hours. 4) Assessment: outcome not priority; normal BP is
4. Blood pressure of 100/82. 120/80
4/139
1) Implementation: outcome not a problem; no
The nurse prepares to interaction with ACE inhibitors; is an SSRI
administer the initial dose of antidepressant
oral enalapril (Vasotec) 20 mg
in the morning. Which 2) CORRECT - Implementation: outcome potential
medication should the nurse problem; may promote significant diuresis; first dose
question giving to the client? of ACE inhibitors increases risk of "first dose"
phenomenon due to vasodilation; combination of
1. 20 mg oral escitalopram vasodilation and diuresis increases risk of
(Celexa) in the morning. orthostatic hypotension
2. 40 mg oral furosemide
(Lasix) in the morning. 3) Implementation: outcome not a problem; no
3. 300 mg of oral gabapentin interaction; gabapentin classified as antiseizure
medication; off-label use for neuropathic pain
(Neurontin) twice daily.
4. 10 mg zolpidem (Ambien) at
bedtime. 4) Implementation: outcome not a problem; is a
hypnotic; no interaction with ACE inhibitors
The home care nurse visits a
1) Assessment: outcome desired; risk of infection at
client with a halo fixator pin sites; client should be taught signs of
traction device. Which client inflammation and infection
statement MOST concerns the
nurse? 2) Implementation: outcome desired; showers
increase risk of infection at pin sites
3) CORRECT - Implementation: outcome not
1. "My wife looks at the pin sites desired and may be a problem; client is not able to
every day." turn with halo device; increases the risk of injury to
2. "I like to bathe in the tub." self and others
3. "I drove to the library
yesterday." 4) Implementation: outcome desired; difficulty
4. "I drink with a straw." manipulating cup or glass due to immobilized neck
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The nurse cares for a client
1) CORRECT - Assessment: outcome desired; clients
diagnosed with depression. with depression may have increased or decreased
Which statement by the client sleep time
indicates improvement?
2) Assessment: outcome not desired; lack of
1. "I have been sleeping 6 hours appetite is a frequent sign of depression
at night."
2. "I have lost 2 lbs in the past 3) Assessment: outcome not desired; lack of
week." concentration is sign of depression
3. "Lately, I have trouble
watching television." 4) Assessment: outcome not desired; is a sign of
4. "I have much less muscle anxiety
tension now."
The nurse on the maternity unit
1) CORRECT - Implementation: outcome desired;
must accept a transfer client autoimmune disease; not infectious
from a medical/surgical unit.
The nurse considers which 2) Implementation: outcome not desired; possible
transfer client appropriate? skin damage and suppression of bone marrow with
decreased white-blood-cell levels; increased risk
1. A 38-year-old client with a for infection
diagnosis of systemic lupus
erythematosus. 3) Implementation: outcome not desired;
2. A 45-year-old client generalized skin infection of deeper connective
receiving daily external tissue; usually caused by Streptococcus or
radiation therapy treatments Staphylococcus; increased risk for infection
for breast cancer.
3. A 58-year-old client 4) Implementation: outcome not desired; elderly
receiving antibiotic treatment clients receiving long-term antibiotic therapy are at
for cellulitis of the left leg. risk for Clostridium difficile infection; highly
4. A 74-year-old client who has contagious; increased risk for infection
received intravenous
antibiotics for 7 days. [Show Less]