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1) The nurse cares for a client with a cuffed tracheostomy tube. Before performing oral care, the nurse notes that the client's tracheostomy$14.99
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1) The nurse cares for a client with a cuffed tracheostomy tube. Before performing oral care, the nurse notes that the client's tracheostomy
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1) The nurse cares for a client with a cuffed tracheostomy tube. Before performing oral care, the nurse notes that the client's tracheostomy
1) The nurse cares for a client with a cuffed tracheostomy tube. Before performing oral care, the nurse notes that the client's tracheostomy c
1. Leave th...
1 the nurse cares for a client with a cuffed tracheostomy tube before performing oral care
the nurse notes that the clients tracheostomy
2 a young adult brings a friend to the emergency depart
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1) The nurse cares for a client with a cuffed tracheostomy tube. Before performing oral care, the nurse notes that the
client's tracheostomy c
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 f
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 pressure
4) Implementation: outcome not desired; increases the risk of trauma to lower airways
3) The client tells the clinic nurse that the client is thinking about using nicotine polacrilex (Nicorette). Which
question is MOST important
1. "Have you tried other methods to stop smoking?"
2. "How long have you been smoking?"
3. "Have you ever had chest pain?"
4. "Do you have a partial dental bridge?"
1) Assessment: outcome not priority but may be appropriate; can be asked as part of assessment
,2) Assessment: outcome not priority but may be appropriate; should be assessed for further teaching
3) CORRECT - Assessment: outcome priority; action of nicotine is vasoconstriction; increases heart rate and
myocardial oxygen consumption; inc
4) Assessment: outcome may be appropriate but not priority; gum is place between cheek and gums; may stain
dental work
4) The nurse cares for the client with a client controlled analgesia (PCA) pump. The nurse determines that the client
has pressed the button 1
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 radiat
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
5) A pregnant woman receives an epidural anesthetic. After administration of the epidural anesthetic, the client's
blood pressure changes from
1. Place the client flat on her back.
2. Elevate the head of the bed 30 degrees.
3. Place the client on her left side with her legs flexed.
4. Place the client supine with the foot of the bed elevated.
1) Implementation: outcome not desired; no increase in venous return
2) Implementation: outcome not desired; will decrease venous return
3) CORRECT - Implementation: outcome desired; will increase venous return and cardiac output; fetal pressure on
inferior vena cava reduced
4) Implementation: outcome not desired; elevation of legs will increase venous return, but fetal pressure on vena
cava will prevent blood retu
8) 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."
4. "I drink with a straw."
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 inju
4) Implementation: outcome desired; difficulty manipulating cup or glass due to immobilized neck
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