A nurse is caring for a toddler at a well-child visit
when the mother calls to the nurse, "Help! My baby
is choking on his food." Which of the following
findings indicates the toddler has an airway
obstruction?
Inability of the toddle to cry or speak.
A nurse is planning care for a client who has a
prescription for collection of a sputum specimen
for culture and sensitivity. Which of the
following actions should the nurse take when
obtaining the specimen?
Collect the specimen upon arising in the morning.
in the morning it's easier to cough up secretions
deepest specimens are usually collected in
morning try to collect before breakfast
prior to coughing into container: rinse mouth and
deep breathe
A nurse is caring for a client who has a history of
dysrhythmias. Upon entering the room, the nurse
discovers the client is unresponsive to verbal or
painful stimuli, has no respirations, and is pulseless.
Which of the following actions should the nurse
take first?
Start chest compressions.
give priority to the factor or situation posing the
greatest safety risk.
, A nurse is teaching a client who is recovering from
gallbladder surgery how to use an incentive
spirometer. Which of the following information
should the nurse include in the teaching?
Hold breath for 5 seconds after goal volume is
reached.
Rationale: decreases collapse of alveoli, which helps
prevent risk of atelectasis and pneumonia
nurse is preparing to remove an NG tube for a client
who had a partial colectomy. Which of the following
actions should the nurse take?
Pinch the NG tube while removing the tube.
decreases risk of aspiration of any GI contents
A nurse is providing teaching to a client who has a
new colostomy about proper care. Which of the
following information should the nurse include in the
teaching.
Cleanse the skin around the stoma with warm
water.
using soap can leave a residue and cause poor
adherence of pouch
A nurse is performing a straight urinary
catheterization for a female client who has urinary
retention. Which of the following actions indicates
the nurse is maintaining sterile technique?