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1. A client has expressive aphasia following a stroke. Which of the following methods should be used when communicating with the client?
- A. Speak slowly
- B. Provide written instructions
- C. Use a picture board
- D. Write on a whiteboard
Correct answer: C
Rationale: When communicating with a client who has expressive aphasia, using a picture board is an effective method as it provides an alternative means of communication. Option A, speaking slowly, may not improve understanding for someone with expressive aphasia. Option B, providing written instructions, may also be challenging for individuals with this condition. Option D, writing on a whiteboard, may not be as helpful as using a picture board in facilitating communication for a client with expressive aphasia.
2. How should a healthcare professional assess and manage a patient with a tracheostomy?
- A. Monitor for signs of infection and ensure airway patency
- B. Suction airway secretions and provide humidified air
- C. Inspect stoma site and clean with saline
- D. Provide education on tracheostomy care
Correct answer: A
Rationale: Correct answer: Monitoring for signs of infection and ensuring airway patency is crucial in managing a patient with a tracheostomy. This involves observing for redness, swelling, or discharge at the stoma site, as well as assessing for any signs of respiratory distress. Choice B, suctioning airway secretions and providing humidified air, is important for maintaining airway hygiene but may not be the initial assessment priority. Choice C, inspecting the stoma site and cleaning with saline, is part of routine tracheostomy care but does not address immediate assessment and management needs. Choice D, providing education on tracheostomy care, is valuable but not the primary action required in the assessment and management of a patient with a tracheostomy.
3. When caring for a client with a wound infection, what should the nurse prioritize?
- A. Change the dressing daily
- B. Cleanse the wound with an antiseptic solution
- C. Apply a wet-to-dry dressing to the wound
- D. Perform a wound culture before administering antibiotics
Correct answer: D
Rationale: The nurse should prioritize performing a wound culture before administering antibiotics to ensure appropriate treatment. This step helps identify the specific infecting organism and its susceptibility to different antibiotics, guiding effective antibiotic therapy. Changing the dressing daily (Choice A) is important but comes after assessing the infection and initiating appropriate treatment. Cleansing the wound with an antiseptic solution (Choice B) and applying a wet-to-dry dressing (Choice C) are interventions that may be necessary but are secondary to determining the most suitable antibiotic therapy based on the wound culture results.
4. What is the nurse's priority when caring for a client with a tracheostomy who is showing signs of respiratory distress?
- A. Administer a bronchodilator
- B. Suction the tracheostomy
- C. Notify the physician immediately
- D. Increase the oxygen flow rate
Correct answer: B
Rationale: The correct answer is to suction the tracheostomy. When a client with a tracheostomy is experiencing respiratory distress, the priority intervention is to clear the airway by suctioning the tracheostomy to remove secretions that may be obstructing the air passage. Administering a bronchodilator (Choice A) may be considered if bronchospasm is present, but the immediate focus should be on clearing the airway. Notifying the physician (Choice C) is important but should not delay the immediate intervention of suctioning. Increasing the oxygen flow rate (Choice D) may provide temporary relief, but addressing the root cause of the distress by suctioning is the priority.
5. A nurse is assessing the remote memory of an older adult client who has mild dementia. Which of the following questions should the nurse ask the client?
- A. Can you tell me who visited you today?
- B. What high school did you graduate from?
- C. Can you list your current medications?
- D. What did you have for breakfast yesterday?
Correct answer: B
Rationale: The correct answer is B: 'What high school did you graduate from?' Remote memory involves recalling past events, such as educational history, making option B the most appropriate question to assess this aspect of memory in an older adult with mild dementia. Option A pertains to recent memory. Option C focuses on short-term memory. Option D addresses recent memory as well.
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