When the nurse is determining the appropriate size of an oropharyngeal airway to insert, what part of a client’s body should she measure?

A. corner of the mouth to the tragus of the ear

B. corner of the eye to the top of the ear

C. tip of the chin to the sternum

D. tip of the nose to the earlobe

Correct Answer: corner of the mouth to the tragus of the ear
Rationale: Correct! When sizing an oropharyngeal airway, the nurse should measure from the corner of the client’s mouth to the tragus of the ear. This measurement ensures that the airway is the appropriate length to reach the pharynx without being too long or too short. Choices B, C, and D are incorrect as they do not provide the correct anatomical landmarks for determining the size of an oropharyngeal airway. Measuring from the corner of the mouth to the tragus of the ear is a standard method to ensure proper airway size and prevent complications during airway management.

How many temporary teeth should the nurse expect to find in a 5-year-old client’s mouth?

• A. up to 10
• B. up to 15
• C. up to 20
• D. up to 32

Correct Answer: up to 20
Rationale: A 5-year-old child can have up to 20 temporary (deciduous or baby) teeth. The first tooth usually erupts by age 6 months, and the last by age 30 months. All temporary teeth are usually shed between 6 and 13 years of age. Therefore, a 5-year-old child should have up to 20 temporary teeth. The correct answer is 'up to 20.' Choices A, B, and D are incorrect because the correct number of temporary teeth in a 5-year-old child's mouth is up to 20, not 10, 15, or 32.

Which of the following is not a function of parathyroid hormone?

• A. moving calcium from bones to the bloodstream
• B. inhibiting renal tubular reabsorption of phosphorus
• C. promoting renal tubular reabsorption of calcium
• D. enhancing renal production of vitamin D metabolites

Correct Answer: inhibiting renal tubular reabsorption of phosphorus
Rationale: The correct answer is 'inhibiting renal tubular reabsorption of phosphorus.' Parathyroid hormone actually inhibits renal tubular reabsorption of phosphorus, making this choice the opposite of its function. Parathyroid hormone functions to move calcium from bones to the bloodstream (Choice A), promote renal tubular reabsorption of calcium (Choice C), and enhance renal production of vitamin D metabolites (Choice D). Therefore, all other choices are functions of parathyroid hormone except for the inhibition of phosphorus reabsorption.

If a visitor accidentally knocks over a plastic pleural drainage system connected to a client, causing it to crack, what should the nurse do first?

• A. Observe the client’s response.
• B. Notify the physician.
• C. Change the drainage system.
• D. Observe for leaks.

Correct Answer: C: Change the drainage system.
Rationale: When a pleural drainage system is cracked, the nurse's initial action should be to change the drainage system. This is essential to prevent potential complications like air leaks or infections. While observing the client’s response and checking for leaks are important steps, they are secondary to addressing the immediate issue of the cracked system. Notifying the physician, though necessary, can be carried out once the primary concern of the damaged system is resolved.

Nurses caring for clients who have cancer and are taking opioids need to assess for all of the following except:

• A. tolerance.
• B. constipation.
• C. sedation.
• D. addiction.

Correct Answer: addiction.
Rationale: When caring for clients with cancer who are taking opioids, nurses need to assess for tolerance, constipation, and sedation as these are common side effects of opioid use. Addiction, however, is not a primary concern when treating pain in terminally ill clients. Terminally ill patients are usually not at risk of developing addiction to opioids due to their short life expectancy and the focus on pain management rather than the potential for addiction. Therefore, the correct answer is 'addiction.' Choices A, B, and C are essential considerations when managing clients on opioids for pain control.