Med Surgical Nclex

MED SURGICAL NCLEX The client coughs and the tube is dislodged. What is the initial nursing action? 1. Call the health care provider to reinsert the tube. 2. Ventilate the client using a manual resuscitation bag and face mask. 3. Cover the tracheostomy site with a sterile dressing to prevent infection. 4. Call the respiratory therapy department to reinsert the tracheostomy tube. - ANSWER 2. Ventilate the client using a manual resuscitation bag and face mask The nurse is changing the tapes on a tracheostomy tube. The clinic nurse instructs an adolescent with iron deficiency anemia about the administration of oral iron preparations. The nurse should tell the adolescent that it is best to take the iron with which item? 1. Cola 2. Soda 3. Water 4. Tomato juice - ANSWER 4. Tomato juice The home care nurse visits a client with chronic obstructive pulmonary disease (COPD) who is on home oxygen at 2 L per minute. The client's respiratory rate is 22 breaths per minute, and the client is complaining of increased dyspnea. The nurse should take which initial action? 1. Determine the need to increase the oxygen. 2. Call emergency services to come to the home. 3. Reassure the client that there is no need to worry. 4. Collect more information about the client's respiratory status - ANSWER 4. Collect more information about the client's respiratory status The nurse should implement which measures to prevent infection in a hospitalized immunocompromised client? Select all that apply. 1. Use strict aseptic technique for all invasive procedures. 2. Use good hand-washing technique before touching the client. 3. Insert a urinary catheter to eliminate the need to use a bedpan. 4. Keep fresh flowers and potted plants out of the client's room. 5. Place the client in a semiprivate room with another client who is immunocompromised. 6. Keep frequently used equipment such as a blood pressure cuff in the client's room for use by the client. - ANSWER 1. Use strict aseptic technique for all invasive procedures. 2. Use good hand-washing technique before touching the client. 4. Keep fresh flowers and potted plants out of the client's room. 6. Keep frequently used equipment such as a blood pressure cuff in the client's room for use by the client.