1. A nurse is performing a tracheostomy care for a client who is postoperative following a laryngectomy. Which of the following actions should the nurse
... [Show More] take when suctioning the clients airway?
- B. Apply suction for 10 seconds.
Rationale: nurse should apply suction for only 5-15 secs to minimize oxygen loss
2. A Nurse is preparing to administer a long acting insulin to a client who has diabetes mellitus. Which of the flowing actions should the nurse plan to take first? - B. Check the insulin dose with another licensed nurse.
Rationale: The greatest risk to the client is injury due to a medication error. Therefore, the priority action is for the nurse to validate the correct dose of insulin with another licensed nurse prior to administration. Insulin is a high-alert medication and incorrect dosages can be fatal for the client.
3. A nurse is caring for an older adult client in the PACU following general anesthesia. Which of the following findings should the nurse report to the provider?
-C. Audible stridor
Rationale: Audible stridor, or a high-pitched sound heard in the client's airway indicates edema, laryngeal spasm, secretions, or some type of airway obstruction that could become life-threatening. The nurse should report this finding to the provider.
4. A charge nurse is planning an educational session for staff nurses about working with parents whose terminally ill children are candidates for donating their organs. Which of the following information should the nurse plan to include?
- B. The family can have the child in an open casket without fearing that the organ donation might disfigure the child's body.
Rationale: Removal of organs does not damage or violate the child's body in a way that would prevent an open casket funeral.
5. A nurse manager is planning to make changes to the current scheduling system on the unit. To facilitate the staff's acceptance of this change, which of the following should the nurse manager take first?
- A. Provide information about scheduling issues to the staff.
Rationale: The first stage of the change process is the unfreezing stage, when the nurse should inform the staff about the current staffing issues. This can increase their understanding of why changes are necessary.
6. A nurse is assessing a client who is receiving blood transfusion. Which of the following findings should the nurse indicate to the nurse that the client is having a hemolytic transfusion reaction?
- B. Low back pain
Rationale: The nurse should expect low back pain in a client who is having a hemolytic transfusion reaction.
7. A nurse is assessing a client who has macular degeneration. Which of the following findings should the nurse expect?
- C. Decreased central vision
Rationale: The nurse should expect a client who has macular degeneration to have a decrease or loss of central vision due to bleeding into the macula or yellow spots under the retina.
8. A nurse working in a long-term care facility is assessing an adult client. Which of the following findings places the client at risk for development of a pressure injury?
- D. Recent weight loss
Rationale: Weight loss can increase the risk for pressure injury. Inadequate nutrition will cause decreased nutrients for the skin and tissues and increases the chance for shearing against the bony prominences. [Show Less]