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1. When should a healthcare provider suction a client's tracheostomy?
- A. When the client is hypotensive
- B. When the client is irritable
- C. When the client is flushed
- D. When the client is bradycardic
Correct answer: B
Rationale: Irritability is an early sign that suctioning is required to clear secretions in a client with a tracheostomy. Hypotension, flushing, and bradycardia are not direct indicators for suctioning a tracheostomy. Hypotension may indicate a need for fluid resuscitation or other interventions, flushing could be due to various reasons like fever, and bradycardia may require evaluation for cardiac causes.
2. A client who has undergone vein ligation and stripping to treat varicose veins should be instructed to do which of the following activities during discharge teaching?
- A. Remain sedentary for 2-3 days
- B. Walk for 1-2 hours each day
- C. Wear compression stockings only at night
- D. Elevate legs while sitting
Correct answer: B
Rationale: The correct answer is B: 'Walk for 1-2 hours each day.' After vein ligation and stripping, walking helps promote circulation and aids in the recovery process. Option A is incorrect as remaining sedentary for 2-3 days can lead to decreased circulation and potentially increase the risk of complications. Option C is incorrect because compression stockings should typically be worn during the day to support circulation. Option D is incorrect as elevating the legs while sitting is beneficial, but walking is more effective in promoting circulation and recovery in this case.
3. A client is using a metered-dose inhaler (MDI) for asthma management. Which of the following actions by the client indicates an understanding of the teaching?
- A. Inhale rapidly through the mouth after pressing down on the inhaler
- B. Exhale completely before pressing down on the inhaler
- C. Hold your breath for 5-10 seconds after inhaling
- D. Inhale slowly while pressing down on the inhaler
Correct answer: C
Rationale: The correct answer is to hold your breath for 5-10 seconds after inhaling when using a metered-dose inhaler (MDI) for asthma management. This action ensures proper medication absorption in the lungs. Inhaling rapidly (choice A) may cause the medication to impact the mouth/throat rather than the lungs. Exhaling completely before inhalation (choice B) does not optimize medication delivery. Inhaling slowly (choice D) may not allow the medication to reach the lungs effectively.
4. What are the nursing interventions for a patient experiencing hypoglycemia?
- A. Administer glucose or dextrose and monitor blood sugar levels
- B. Monitor vital signs and provide a high-carbohydrate snack
- C. Monitor for sweating and confusion
- D. Provide insulin and assess for hyperglycemia
Correct answer: A
Rationale: The correct answer is A. Administering glucose or dextrose is a crucial nursing intervention for a patient experiencing hypoglycemia as it helps to quickly raise blood sugar levels. Monitoring blood sugar levels is essential to ensure that the patient's glucose levels normalize. Choice B is incorrect because providing a high-carbohydrate snack may not be sufficient to rapidly raise blood sugar levels in severe hypoglycemia. Choice C is incorrect because while monitoring for sweating and confusion is important in hypoglycemia, it is not a direct nursing intervention. Choice D is incorrect as providing insulin would lower blood sugar levels further, worsening hypoglycemia.
5. What is the priority for the nurse when caring for a patient with a chest tube?
- A. Ensure tube patency and observe for air leaks
- B. Maintain sterile technique during dressing changes
- C. Monitor drainage and record output
- D. Observe for signs of infection and monitor for subcutaneous emphysema
Correct answer: A
Rationale: The priority for the nurse when caring for a patient with a chest tube is to ensure tube patency and observe for air leaks. This is essential to prevent complications such as pneumothorax and ensure the patient's lung function. While maintaining sterile technique during dressing changes, monitoring drainage, recording output, and observing for signs of infection and subcutaneous emphysema are also important, ensuring tube patency takes precedence as it directly impacts the patient's respiratory status and overall safety.
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