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1. A client with a tracheostomy is exhibiting signs of respiratory distress. What should the nurse do first?
- A. Notify the healthcare provider
- B. Suction the tracheostomy
- C. Administer a bronchodilator
- D. Increase the oxygen flow rate
Correct answer: B
Rationale: When a client with a tracheostomy is experiencing respiratory distress, the priority action is to suction the tracheostomy to clear the airway and improve breathing. This helps remove secretions or blockages that may be causing the distress. Notifying the healthcare provider (Choice A) can be done after ensuring immediate airway clearance. Administering a bronchodilator (Choice C) would not address the primary issue of airway clearance in a tracheostomy patient. Increasing the oxygen flow rate (Choice D) may be necessary but should come after ensuring the airway is clear.
2. What is the appropriate action for a healthcare professional when administering a blood transfusion?
- A. Verify the patient's identity
- B. Monitor vital signs
- C. Stay with the patient during the first 15 minutes
- D. Stop the transfusion if a reaction occurs
Correct answer: A
Rationale: The appropriate action for a healthcare professional when administering a blood transfusion is to verify the patient's identity. This step is essential to ensure that the correct blood product is given to the right patient, preventing any errors or adverse reactions. While monitoring vital signs and staying with the patient during the initial phase of the transfusion are also important steps, the primary action of verifying the patient's identity takes precedence to uphold patient safety and prevent any potential harm.
3. A client with a new diagnosis of type 2 diabetes mellitus inquires about information concerning oral antidiabetic agents. In addition to the provider, where should the nurse refer the client for information?
- A. Family members
- B. Pharmacist
- C. Dietitian
- D. American Diabetes Association
Correct answer: D
Rationale: The correct answer is D: American Diabetes Association. The American Diabetes Association is a reputable source that provides credible information on managing diabetes. While family members can offer support, they may not have the specialized knowledge on oral antidiabetic agents. Pharmacists are knowledgeable about medications but may not provide comprehensive information on diabetes management. Dietitians can offer valuable advice on nutrition but may not cover specific details about oral antidiabetic agents. Therefore, referring the client to the American Diabetes Association ensures access to accurate and detailed information related to their condition.
4. A nurse is reinforcing teaching with a client about cancer prevention. The nurse should include that frequent consumption of which of the following foods increases the risk for developing cancer?
- A. Lamb
- B. Poultry
- C. Tuna
- D. Beef
Correct answer: A
Rationale: The correct answer is A: Lamb. Lamb is high in saturated fat, which is linked to an increased risk of developing cancer. Choice B (Poultry) is a lean protein source and is not associated with an increased cancer risk. Choice C (Tuna) is a good source of omega-3 fatty acids, which have anti-inflammatory properties that may reduce cancer risk. Choice D (Beef) is also high in saturated fat like lamb, making it a poor choice for cancer prevention.
5. A client is undergoing radiation therapy. Which of the following actions should the nurse take to prevent skin irritation?
- A. Apply heat packs to the area
- B. Use perfumed soap to cleanse the area
- C. Keep the area moist with lotion
- D. Avoid sun exposure to the treated area
Correct answer: D
Rationale: Avoiding sun exposure is crucial to prevent skin irritation and burns in clients undergoing radiation therapy. Radiation therapy makes the skin more sensitive to sunlight, increasing the risk of skin damage. Applying heat packs (choice A) can exacerbate skin irritation as heat can further irritate the skin that is already sensitive due to radiation. Using perfumed soap (choice B) can further irritate the skin due to its harsh chemicals, potentially worsening skin reactions. While keeping the area moist with lotion (choice C) may seem beneficial, some lotions contain ingredients that can worsen skin reactions during radiation therapy. Therefore, avoiding sun exposure to the treated area (choice D) is the most appropriate action to prevent skin irritation and damage during radiation therapy.
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