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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. When assessing a client with signs of delirium, which factor should be the nurse's priority in determining the cause?
- A. Medication history
- B. Fluid and electrolyte imbalances
- C. Psychosocial stressors
- D. Environmental factors
Correct answer: B
Rationale: When a nurse assesses a client with signs of delirium, the priority in determining the cause should be focusing on fluid and electrolyte imbalances. Delirium can often be linked to imbalances in these essential elements, making it crucial to address them promptly. While medication history, psychosocial stressors, and environmental factors can also contribute to delirium, they should be assessed after addressing fluid and electrolyte imbalances due to their immediate impact on cognitive function.
3. How should a healthcare provider manage a patient with Type 1 diabetes?
- A. Administer insulin and monitor blood glucose levels
- B. Provide a low-carbohydrate diet and oral hypoglycemics
- C. Administer oral hypoglycemics and provide dietary education
- D. Provide a high-protein diet and insulin injections
Correct answer: A
Rationale: Type 1 diabetes is managed with insulin administration and regular blood glucose monitoring. Choice A is correct because administering insulin is essential in Type 1 diabetes management to help regulate blood glucose levels. Choices B, C, and D are incorrect because Type 1 diabetes requires insulin therapy as the primary treatment, not oral hypoglycemics or dietary modifications like low-carbohydrate or high-protein diets. Monitoring blood glucose levels is crucial in adjusting insulin doses and ensuring optimal management of the condition.
4. What is the correct way to assess for pitting edema?
- A. Press over the bony area for 5 seconds and release
- B. Press over the skin for 10 seconds and check for discoloration
- C. Press the area and check for the presence of rash
- D. Press the skin and assess for rebound tenderness
Correct answer: A
Rationale: The correct way to assess for pitting edema is to press over a bony area, typically the tibia, for 5 seconds and then release. This allows for the identification of pitting edema, characterized by an indentation that persists for a few seconds. Choice B is incorrect as pitting edema assessment does not involve checking for discoloration. Choice C is incorrect as the presence of a rash is not indicative of pitting edema. Choice D is incorrect as rebound tenderness is a different assessment used for abdominal conditions, not for pitting edema.
5. A nurse in a long-term care facility is assisting with an in-service for newly hired assistive personnel about legal issues within the facility. Which of the following should the nurse include as an example of assault?
- A. Threatening to withhold food from a client
- B. Informing a client about an upcoming procedure
- C. Informing a client about risks of refusing treatment
- D. Informing a client that they will be given an injection against their will
Correct answer: D
Rationale: The correct answer is D because assault involves threatening a client with harm or unwanted procedures. In this scenario, informing a client that they will be given an injection against their will constitutes assault. Choices A, B, and C do not involve the element of threatening harm or unwanted procedures, making them incorrect. Choice A is more related to neglect, choice B is related to informing the client about a procedure, and choice C is related to informed consent and refusal of treatment, not assault.
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