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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. How can pain in a post-operative patient be managed effectively?
- A. Administer analgesics as prescribed
- B. Encourage deep breathing exercises
- C. Provide distractions
- D. All of the above
Correct answer: D
Rationale: Managing pain in a post-operative patient requires a multimodal approach, which includes both pharmacological and non-pharmacological strategies. Administering analgesics as prescribed helps in controlling pain pharmacologically. Encouraging deep breathing exercises can aid in pain management by promoting relaxation and reducing anxiety. Providing distractions, such as music or activities, can help divert the patient's attention from pain. Therefore, all the given options are essential components of an effective pain management plan for post-operative patients.
3. A nurse is caring for a client with a chest tube post-surgery. What is the most important assessment?
- A. Ensure the chest tube is clamped periodically
- B. Check for air leaks and ensure proper chest tube function
- C. Encourage deep breathing and coughing every 2 hours
- D. Ensure the client is positioned in a high Fowler's position
Correct answer: B
Rationale: The correct answer is B: 'Check for air leaks and ensure proper chest tube function.' This is the most important assessment for a client with a chest tube post-surgery because it ensures that the chest tube is functioning properly. Checking for air leaks helps prevent complications such as pneumothorax or hemothorax. Choice A is incorrect because clamping the chest tube periodically can lead to serious complications and should not be done unless specifically ordered by a healthcare provider. Choice C is important for promoting lung expansion but is not the most critical assessment related to the chest tube. Choice D is also important for respiratory function but is not the priority when assessing a chest tube post-surgery.
4. What is the priority nursing action for a patient with an acute asthma attack?
- A. Administer a bronchodilator
- B. Monitor oxygen saturation
- C. Position the patient in a high Fowler's position
- D. Call for assistance
Correct answer: A
Rationale: The correct answer is to administer a bronchodilator. During an acute asthma attack, the priority is to open the airways and improve breathing. Bronchodilators are the first-line treatment for asthma attacks as they help dilate the bronchioles, allowing for better airflow. Monitoring oxygen saturation is important but not the priority when the patient is in distress. Placing the patient in a high Fowler's position can help with breathing but is not the initial priority. Calling for assistance can be done after initiating the appropriate treatment.
5. 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.
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