1. A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and tenacious secretions. Which of the following is an acceptable method for thenurse to use to thin this client's secretions?
1) Provide humidified oxygen. → want to hyperoxygenate prior to suction...
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1. A nurse is caring for a client who is postoperative following a tracheostomy, and has
copious and tenacious secretions. Which of the following is an acceptable method for
thenurse to use to thin this client's secretions?
1) Provide humidified oxygen. → want to hyperoxygenate prior to suction
2) Perform chest physiotherapy prior to suctioning.
3) Prelubricate the suction catheter tip with sterile saline when suctioning the airway.
4) Hyperventilate the client with 100% oxygen before suctioning the airway..
2. Following admission, a client with a vascular occlusion of the right lower extremity calls
the nurse and reports difficulty sleeping because of cold feet. Which of the following
nursing actions should the nurse take to promote the client's comfort?
1) Rub the client's feet briskly for several minutes.
2) Obtain a pair of slipper socks for the client.
3) Increase the client's oral fluid intake.
4) Place a moist heating pad under the client's feet.
3. A nurse is caring for a client who is 4 hr postoperative following a transurethral
resection of the prostate (TURP). Which of the following is the priority finding for
thenurse report to the provider?
1) Emesis of 100 mL
2) Oral temperature of 37.5° C (99.5° F)
3) Thick, red-colored urine
4) Pain level of 4 on a 0 to 10 rating scale
4. A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a
prescription for a hypothermia blanket. The nurse should monitor the client for which of
the following adverse effects of the hypothermia blanket?
1) Shivering → The process of shivering is detrimental since it counteracts cooling induction,
consumes energy, and can contribute to increased ICP, increased energy expenditure and brain O2
consumption.
2) Infection
3) Burns
4) Hypervolemia
,5. A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes
mellitus. Which of the following statements by the client indicates an understanding of
the
, teaching?
1) "I will carry a complex carbohydrate snack with me when I exercise."
2) "I should exercise first thing in the morning before eating breakfast."
3) "I should avoid injecting insulin into my thigh if I am going to go
running."
4) "I will not exercise if my urine is positive for ketones." → not having enough
insulin to use, the sugar in the blood can also cause the body to burn fat for fuel.
When the body starts to burn fat for fuel, substances called ketones are produced.
People w/diabetes shouldn’t exercise if the have high levels of ketones in their
blood because it can make them really sick & cause their insulin levels to increase.
6. A nurse notes a small section of bowel protruding from the abdominal incision of a client
who is postoperative. After calling for assistance, which of the following actions should
thenurse take first?
1) Cover the client's wound with a moist, sterile dressing.
2) Have the client lie supine with knees flexed.
3) Check the client's vital signs.
4) Inform the client about the need to return to surgery.
7. A nurse is collecting data from a client who has alcohol use disorder and is experiencing
metabolic acidosis. Which of the following manifestations should the nurse expect?
1) Cool, clammy skin.
2) Hyperventilation → S/Sx of Metabolic Acidosis: jaundice, tachycardia (inc. HR)
Confusion, fatigue, rapid and shallow breathing, headache, sleepiness,
3) Increased blood pressure
4) Bradycardia
8. A nurse is reinforcing discharge teaching with a client following a cataract extraction.
Which of the following should the nurse include in the teaching?
1) Avoid bending at the waist. → brings more pressure to the eyes; bending over can cause a
rush of blood to your head that interferes with recovery
2) Remove the eye shield at bedtime.
3) Limit the use of laxatives if constipated.
4) Seeing flashes of light is an expected finding following extraction.
9. A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg
daily. The client refuses breakfast and reports nausea. Which of the following actions
should the nurse take first?
1) Suggest that the client rests before eating the meal.
2) Request a dietary consult.
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