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A nurse is reviewing protocol in preparation for suctioning
secretions from a client who has a new tracheostomy.
Which of the following actions should the nurse plant to take?
a) Use a resuscitation bag with 80% oxygen prior to the
procedure.
b) Select a suction catheter that is half the size of the lumen.
c) Place the end of the suction catheter in water-soluble lubricant.
d) Adjust the wall suction apparatus to a pressure of 170 mm Hg. -
ANSWER ANSWER: B.- The nurse should select a suction catheter that
is half the size of the lumen to prevent hypoxemia
and trauma to the mucosa
A nurse in a clinic is caring for a middle adult client who states,
"the doctor says that, since I am an average risk for colon cancer, I
should have a routine screening/ what does that involve?" Which of the
following responses should the nurse make?
a) "I'll get a blood sample from you and send it for a screening test."
b) "Beginning at age 60, you should have a colonoscopy."
c) "You should have a fecal occult blood test every year."
d) "The recommendation is to have a sigmoidoscopy every 10 - ANSWER
ANSWER: C.- Colorectal cancer screening for clients who are at
average risk begins at age 50. One option for screening is a fecal occult
blood test annually
A nurse has just inserted an NG tube for a client. Which of the
following findings should the nurse expect to confirm
correct tube placement?
,a) The tube aspirate has a pH of 7.
b) An x-ray shows the end of the tube above the pylorus.
c) Bowel sounds are present on auscultation.
d) The client reports relief of nausea. - ANSWER ANSWER: B.- An
abdominal x-ray showing the end of the tube above the pylorus
indicates gastric placement
A nurse is preparing to administer 0.5 mL of oral single-dose
liquid medication to a client. Which of the following
actions should the nurse take?
a) Gently shake the container of medication prior to administration.
b) Transfer the medication to a medicine cup.
c) Place the client in a semi-Fowler's position prior to medication
administration.
d) Verify the dosage by measuring the liquid before administering it -
ANSWER ANSWER: A.- The nurse should gently shake the liquid
medication to ensure that the medication is mixed.
A nurse is admitting a client who has rubella. Which of the
following types of transmission-based precautions should the
nurse initiate? a) Droplet
b) Airborne
c) Contact
d) Protective environment - ANSWER ANSWER: A.- Droplet precautions
are a requirement for clients who have infections that spread via droplet
nuclei
that are larger than 5 microns in diameter, including influenza, rubella,
meningococcal pneumonia, and streptococcal pharyngitis. Airborne
precautions are a requirement for clients who have infections that spread
via droplet nuclei that are smaller than 5 microns in diameter, including
varicella, tuberculosis, and measles. Contact precautions are a
requirement for clients who have infections that spread via direct contact
with another person or contact with the environment, including
vancomycin-resistant enterococci, methicillin-resistant Staphylococcus
, aureus, and scabies. Clients who have a compromised immune system,
such as those who have had an allogeneic hematopoietic stem cell
transplant, require a protective environment
A nurse is reviewing client's medication prescription that reads,
"digoxin 0.25 by mouth every day". Which of the following components of
the prescription should the nurse verify with the provider?
a) Medication name
b) Route of administration
c) Medication dose
d) Frequency of administration - ANSWER ANSWER: C.- In the
prescription, the medication dose is not complete. The number 0.25
should be followed by a
unit of measurement, such as mg, to clarify the amount the nurse should
administer
A nurse manager is overseeing the care activities on a unit. For which of
the following situations should the nurse manager intervene due to
HIPAA guidelines?
a) A nurse who is caring for a client reviews the client's medical chart
with a nursing student who is working with the nurse.
b) A nurse asks a nurse from another unit to assist with documentation
for a client.
c) A nurse who is caring for a client returns a call to the person
appointed in the health care proxy to discuss the client's car - ANSWER
ANSWER: B.- Only health care professionals directly caring for a client
should have access to the client's medical
information; therefore, this is a violation of HIPAA guidelines
A nurse is teaching an older adult client who is at risk for osteoporosis
about beginning a program of regular physical activity. Which of the
following types of activity should the nurse recommend?
a) Walking briskly
b) Riding a bicycle
c) Performing isometric exercises