The nurse is assessing a client with a cuffed tracheostomy tube in place who is breathing spontaneously. to evaluate if the client can tolerate cuff deflation to promote speaking and swallowing, what action should the nurse implement?
A. observe the client for coughing colored sputum after drinking a small amount of colored water
B. ask the client to try to speak
C. auscultate for pulmonary crackles after the client drinks a small amount of clear water
D. assess for respiratory distress
Ans: A. observe the client for coughing colored sputum after drinking a small amount of colored water
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The nurse is caring for a patient from a patriarchal culture who has just experienced fetal demise at 30 weeks. The reason for the demise is not readily apparent. Being culturally sensitive, the nurse knows that:
1. The patient will feel that she is a failure at reproduction. 2. The patient will have no feeling toward the fetus. 3. The husband will be very supportive of his wife. 4. The father will not be allowed to see the baby.
The nurse in a pediatric acute-care unit is assigned the following tasks. Which task is not appropriate for the registered to nurse complete?
1. Diagnose an 8-year-old with acute otitis media and prescribe an antibiotic. 2. Listen to the concerns of an adolescent about being out of school for a lengthy surgical recovery. 3. Provide information to a mother of a newly diagnosed 4-year-old diabetic about local support-group options. 4. Diagnose a 6-year-old with Diversional Activity Deficit related to placement in isolation.
MC The client has taken an overdose of lithium. Which of the following signs and symptoms should the nurse assess for?
A. Seizures and hyperactive reflexes B. Purpura and incontinence C. Inability to sleep and vomiting D. Diarrhea and vomiting
The nurse is providing education to an individual with sickle cell anemia. Which activities should the nurse instruct the patient to avoid? (Select all that apply.)
a. Scuba diving b. Contact sports c. Sexual activity d. Long-distance driving e. Skiing in the mountains f. Standing for long periods