Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A. Provide humidified oxygen.
Provide humidified oxygen: Humidification helps prevent the drying of mucous membranes, making secretions more manageable and less tenacious. This is an acceptable method to thinsecretions in a client with a tracheostomy.
B. Prelubricate the suction catheter tip with sterile saline when suctioning the airway.
Prelubricate the suction catheter tip with sterile saline when suctioning the airway: While lubrication with sterile saline is a common practice during suctioning to reduce trauma to the airway, it does not directly address the tenacity of secretions.
C. Perform chest physiotherapy prior to suctioning.
Perform chest physiotherapy prior to suctioning: Chest physiotherapy is a technique used to mobilize respiratory secretions, but it may not directly address the tenacity of secretions.
D. Hyperventilate the client with 100% oxygen before suctioning the airway.
Hyperventilate the client with 100% oxygen before suctioning the airway: Hyperventilation with 100% oxygen is not a routine practice and may lead to respiratory alkalosis. Providinghumidified oxygen is a more appropriate approach.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Medsurg Final Proctored Exam. Take the full exam now
Full Explanation
a. Provide humidified oxygen: Humidification helps prevent the drying of mucous membranes, making secretions more manageable and less tenacious. This is an acceptable method to thin
secretions in a client with a tracheostomy.
b. Prelubricate the suction catheter tip with sterile saline when suctioning the airway: While lubrication with sterile saline is a common practice during suctioning to reduce trauma to the airway, it does not directly address the tenacity of secretions.
c. Perform chest physiotherapy prior to suctioning: Chest physiotherapy is a technique used to mobilize respiratory secretions, but it may not directly address the tenacity of secretions.
d. Hyperventilate the client with 100% oxygen before suctioning the airway: Hyperventilation with 100% oxygen is not a routine practice and may lead to respiratory alkalosis. Providing
humidified oxygen is a more appropriate approach.
Similar Questions
A nurse is assisting with caring for a client who has a new concussion following a motor-
A. Battle's sign
Battle's sign: Battle's sign is bruising over the mastoid process and is not a direct manifestation of increased intracranial pressure.
B. Nuchal rigidity
Nuchal rigidity: Nuchal rigidity (stiff neck) is associated with irritation of the meninges and is not a specific sign of increased intracranial pressure.
C. Lethargy
Lethargy: Lethargy or altered level of consciousness is a common manifestation of increased intracranial pressure. It can range from mild drowsiness to severe impairment of consciousness.
D. Polyuria
Polyuria: Polyuria is not a typical manifestation of increased intracranial pressure. Increased urine output may be associated with other conditions, such as diabetes or diuretic use.
Full Explanation
a. Battle's sign: Battle's sign is bruising over the mastoid process and is not a direct manifestation of increased intracranial pressure.
b. Nuchal rigidity: Nuchal rigidity (stiff neck) is associated with irritation of the meninges and is not a specific sign of increased intracranial pressure.
c. Lethargy: Lethargy or altered level of consciousness is a common manifestation of increased intracranial pressure. It can range from mild drowsiness to severe impairment of consciousness.
d. Polyuria: Polyuria is not a typical manifestation of increased intracranial pressure. Increased urine output may be associated with other conditions, such as diabetes or diuretic use.
A nurse is caring for an older adult client who has dysphagia and left-sided weakness following a stroke. Which of the following actions should the nurse take?
A. Instruct the client to tilt her head back when she swallows.
Instruct the client to tilt her head back when she swallows: This action is not recommended, as it increases the risk of aspiration. Tilted head positions can lead to improper bolus control andswallowing difficulties.
B. Add thickener to fluids.
Add thickener to fluids: This is an appropriate intervention for a client with dysphagia, as thickened fluids are easier to control during swallowing and reduce the risk of aspiration.
C. Place food on the left side of the client's mouth.
Place food on the left side of the client's mouth: This action may not directly address the risk of aspiration associated with dysphagia and left-sided weakness.
D. Serve food at room temperature.
Serve food at room temperature: While serving food at room temperature may be preferred for some clients, it does not directly address the safety concerns associated with dysphagia and left- sided weakness.
Full Explanation
a. Instruct the client to tilt her head back when she swallows: This action is not recommended, as it increases the risk of aspiration. Tilted head positions can lead to improper bolus control and
swallowing difficulties.
b. Add thickener to fluids: This is an appropriate intervention for a client with dysphagia, as thickened fluids are easier to control during swallowing and reduce the risk of aspiration.
c. Place food on the left side of the client's mouth: This action may not directly address the risk of aspiration associated with dysphagia and left-sided weakness.
d. Serve food at room temperature: While serving food at room temperature may be preferred for some clients, it does not directly address the safety concerns associated with dysphagia and left- sided weakness.
A nurse is caring for a client who is postoperative and has developed atelectasis. Which of the following findings should the nurse expect?
A. Increasing dyspnea
Increasing dyspnea: Atelectasis is the collapse of alveoli, leading to decreased lung volume and impaired gas exchange. Dyspnea (difficulty breathing) is a common symptom as the lung's ability to oxygenate the blood is compromised.
B. Dry cough
Dry cough: A dry cough may be present, but it is not specific to atelectasis. It can occur for various reasons postoperatively.
C. Facial flushing
Facial flushing: Facial flushing is not a typical finding in atelectasis. It is more commonly associated with conditions such as fever or allergic reactions.
D. Decreasing respiratory rate
Decreasing respiratory rate: Atelectasis can lead to increased respiratory rate as the body tries to compensate for decreased lung function. A decreasing respiratory rate would be less likely in the presence of atelectasis.
Full Explanation
a. Increasing dyspnea: Atelectasis is the collapse of alveoli, leading to decreased lung volume and impaired gas exchange. Dyspnea (difficulty breathing) is a common symptom as the lung's ability to oxygenate the blood is compromised.
b. Dry cough: A dry cough may be present, but it is not specific to atelectasis. It can occur for various reasons postoperatively.
c. Facial flushing: Facial flushing is not a typical finding in atelectasis. It is more commonly associated with conditions such as fever or allergic reactions.
d. Decreasing respiratory rate: Atelectasis can lead to increased respiratory rate as the body tries to compensate for decreased lung function. A decreasing respiratory rate would be less likely in the presence of atelectasis.