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
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
1. Assess pupil size and reactivity.
2. Assess oxygen saturation levels.
3. Palpate dorsalis pedis pulses.
4. Ask the client if he knows today's date. exchange and possible respiratory arrest
3) Assessment: outcome not priority; most important to assess airway and breathing
4) Assessment: outcome not priority but may be appropriate; drowsiness and euphoria may be seen; not priority
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
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.
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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
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 intake" is written for a client diagnosed with dehydration.
Which finding BEST indicates improving fluid status?
1. Urinary output of 1,500 mL in 24 hours.
2. Serum hematocrit 52%.
3. Oral fluid intake of 900 mL in 24 hours.
4. Blood pressure of 100/82.
1) CORRECT - Assessment: outcome priority; increased amounts of antidiuretic hormone secreted; urine output decreased and concentrated
2) Assessment: outcome not priority; indicates that blood is hemoconcentrated
3) Assessment: outcome not priority; normal intake is 1,500 mL in 24 hours
4) Assessment: outcome not priority; normal BP is 120/80
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 2) CORRECT - Implementation: outcome potential in the morning. Which
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
orthostatic hypotension
(Celexa) in the morning.
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 4) Implementation: outcome not a problem; is a bedtime.
hypnotic; no interaction with ACE inhibitors
The home care nurse visits a client with a halo fixator traction device. Which client statement MOST concerns the nurse?
1. "My wife looks at the pin sites every day."
2. "I like to bathe in the tub."
3. "I drove to the library yesterday."
1) Assessment: outcome desired; risk of infection at pin sites; client should be taught signs of inflammation and infection
2) Implementation: outcome desired; showers increase risk of infection at pin sites
3) CORRECT - Implementation: outcome not desired and may be a problem; client is not able to turn with halo device; increases the risk of injury to self and others
4) Implementation: outcome desired; difficulty
4. "I drink with a straw." manipulating cup or glass due to immobilized neck
The nurse cares for a client diagnosed with depression. Which statement by the client indicates improvement?
1. "I have been sleeping 6 hours at night."
2. "I have lost 2 lbs in the past week."
3. "Lately, I have trouble watching television."
4. "I have much less muscle
tension now."
1) CORRECT - Assessment: outcome desired; clients with depression may have increased or decreased sleep time
2) Assessment: outcome not desired; lack of appetite is a frequent sign of depression
3) Assessment: outcome not desired; lack of concentration is sign of depression
4) Assessment: outcome not desired; is a sign of anxiety
The nurse on the maternity unit must accept a transfer client from a medical/surgical unit.
The nurse considers which transfer client appropriate?
1. A 38-year-old client with a diagnosis of systemic lupus erythematosus.
2. A 45-year-old client
receiving daily external
1) CORRECT - Implementation: outcome desired; autoimmune disease; not infectious
2) Implementation: outcome not desired; possible skin damage and suppression of bone marrow with decreased white-blood-cell levels; increased risk for infection
3) Implementation: outcome not desired;
generalized skin infection of deeper connective tissue; usually caused by Streptococcus or
radiation therapy treatments Staphylococcus; increased risk for infection
for breast cancer.
3. A 58-year-old client receiving antibiotic treatment for cellulitis of the left leg.
4. A 74-year-old client who has received intravenous antibiotics for 7 days.
4) Implementation: outcome not desired; elderly clients receiving long-term antibiotic therapy are at risk for Clostridium difficile infection; highly contagious; increased risk for infection [Show Less]