Question

Which action should the nurse take when caring for a client with a tracheostomy?

Answer 1

Correct Answers:

Keep an extra tracheostomy tube at the bedside.

Rationale :

🫁 A client with a tracheostomy is at risk for accidental decannulation, tube obstruction, or damage to the existing tube, which can rapidly compromise the airway.

🫁 An extra tracheostomy tube of the same size should be readily available so the airway can be re-established quickly if the current tube becomes displaced or unusable.

🫁 Many facilities also keep a smaller-size tracheostomy tube available because swelling or narrowing of the stoma can make reinsertion of the original size difficult.

🫁 Emergency airway equipment, including suction and oxygen supplies, should also remain accessible at the bedside.

🫁 Keeping a replacement tracheostomy tube immediately available is therefore an essential safety intervention for preventing life-threatening airway loss.

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Answer 2

Correct Answers:

Venturi mask

Rationale :

🫁 A Venturi mask delivers a precise and predictable concentration of oxygen by mixing oxygen with room air through specifically sized adapters.

🫁 The device uses the Venturi principle to entrain a controlled amount of room air, resulting in a known fraction of inspired oxygen.

🫁 It is particularly useful for clients who require accurate oxygen delivery, including many clients with chronic obstructive pulmonary disease.

🫁 Different adapters or settings provide specific oxygen concentrations while maintaining sufficient total gas flow to meet the client's inspiratory demand.

🫁 The Venturi mask is therefore the best oxygen delivery device when a precise FiO₂ is required.

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Answer 3

Correct Answers:

Monitor the solution flow rate to prevent hyperglycemia and fluid overload

Rationale :

💧 Total parenteral nutrition contains highly concentrated dextrose, amino acids, electrolytes, vitamins, and other nutrients, making accurate infusion control essential.

💧 Infusing TPN too rapidly can cause hyperglycemia, osmotic diuresis, electrolyte disturbances, and fluid overload.

💧 An electronic infusion pump should be used to maintain the prescribed rate and prevent accidental rapid administration.

💧 Blood glucose, fluid balance, daily weight, electrolytes, and other relevant laboratory values should also be monitored during therapy.

💧 Careful monitoring of the infusion rate is therefore a major intervention for preventing potentially serious TPN-related complications.

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Answer 4

Correct Answers:

Decreased risk for urinary tract infections

Rationale :

🚻 A condom catheter is an external urinary collection device, so it does not require insertion through the urethra into the bladder.

🚻 Avoiding an indwelling urethral catheter significantly decreases opportunities for microorganisms to ascend into the urinary tract.

🚻 Indwelling catheters are an important risk factor for catheter-associated urinary tract infections (CAUTIs), especially when they remain in place for prolonged periods.

🚻 Condom catheters can therefore be an appropriate alternative for selected male clients who need urine collection but do not require bladder drainage for retention.

🚻 The reduced risk of urinary tract infection is the major advantage of an external condom catheter compared with an indwelling catheter.

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Answer 5

Correct Answers:

The client is coughing.
The water is leaking from the client's mouth.

Rationale :

The client is coughing

🥤 Coughing during or immediately after drinking can indicate that fluid has entered or approached the airway rather than passing safely through the esophagus.

🥤 This finding is an important clinical sign of dysphagia and possible aspiration.

🥤 Aspiration can result in hypoxemia, airway obstruction, or aspiration pneumonia if swallowing impairment is not identified.

🥤 The nurse should stop oral intake temporarily as appropriate and perform or arrange further swallowing assessment based on the client's condition and facility protocol.

🥤 Coughing while drinking therefore requires prompt nursing follow-up for swallowing safety.

The water is leaking from the client's mouth

🥤 Leakage of liquid from the mouth suggests impaired lip closure, oral motor control, or coordination of the swallowing process.

🥤 Poor oral control can allow fluid to pool in the mouth or move prematurely toward the pharynx before an effective swallow occurs.

🥤 This increases the client's risk for choking and aspiration, particularly if neurologic or muscular impairment is present.

🥤 The nurse should further evaluate swallowing ability and determine whether texture modification, positioning, or specialist assessment is required.

🥤 Water leaking from the mouth is therefore an abnormal swallowing finding that requires follow-up.

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Answer 6

Correct Answers:

Verifies the tablet can be safely crushed before administration.

Rationale :

💊 A client who has difficulty swallowing tablets may benefit from a crushed medication, but the nurse must first determine whether the specific tablet can safely be altered.

💊 Extended-release, delayed-release, enteric-coated, sublingual, and certain hazardous medications should generally not be crushed because doing so can alter drug release, absorption, or safety.

💊 The nurse should verify the formulation using an approved medication reference or consult the pharmacist before crushing the tablet.

💊 If crushing is contraindicated, an alternative formulation such as a liquid, smaller tablet, or different medication may need to be prescribed.

💊 Verifying that the tablet can safely be crushed therefore promotes both safe swallowing and correct medication delivery.

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Answer 7

Correct Order:

Order : 1 : No answer text available
Order : 2 : No answer text available
Order : 3 : No answer text available
Order : 4 : No answer text available
Order : 5 : No answer text available

Rationale :

🛏️ The nurse should first lower the head of the bed and raise the bed to a comfortable working height to promote safe body mechanics and make repositioning easier.

🛏️ Next, the nurse assists the client to roll away from the side where the nurse is standing, creating space to position the bedpan correctly.

🛏️ The bedpan is then placed securely against the client’s buttocks, and the client is helped back into a flat supine position over the bedpan.

🛏️ The head of the bed is then raised to a comfortable position because a more upright posture promotes normal urinary elimination and comfort.

🛏️ Finally, the bed is lowered for safety and the call light is placed within reach so the client can request assistance when finished.

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Answer 8

Correct Answers:

It enhances coordination of inhalation and medication release.

Rationale :

🫁 A spacer holds the aerosolized medication briefly after it is released from the metered-dose inhaler, giving the child more time to inhale it correctly.

🫁 This reduces the need to perfectly coordinate pressing the inhaler and beginning inhalation at the same moment.

🫁 Improved coordination allows more medication to reach the lower airways and lungs rather than depositing in the mouth or throat.

🫁 Spacers are especially useful for children who may have difficulty performing the precise inhalation technique required with an MDI alone.

🫁 The primary benefit is therefore improved medication delivery through better coordination between actuation and inhalation.

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Answer 9

Correct Answers

Blank 1 Correct Option: dribbling
Blank 2 Correct Option: an obstruction

Rationale :

🚻 An enlarged prostate can compress the prostatic urethra, making it difficult for urine to flow freely from the bladder.

🚻 This obstruction commonly causes lower urinary tract symptoms such as hesitancy, weak stream, incomplete emptying, frequency, and post-void dribbling.

🚻 Dribbling occurs because residual urine remains in the bladder or urethra after voiding and leaks out afterward.

🚻 Progressive obstruction can also lead to urinary retention, bladder distention, recurrent urinary tract infections, and possible kidney complications.

🚻 The nurse should therefore expect dribbling caused by urinary obstruction in a client with an enlarged prostate.

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Answer 10

Correct Answers:

Dark amber urine

Rationale :

💧 Dehydration reduces circulating fluid volume, causing the kidneys to conserve water and produce more concentrated urine.

💧 Concentrated urine contains a higher proportion of dissolved substances, giving it a dark yellow or amber appearance.

💧 The client may also have decreased urine output and an increased urine specific gravity as dehydration progresses.

💧 Additional findings can include dry mucous membranes, tachycardia, hypotension, thirst, and poor skin turgor.

💧 Dark amber urine therefore supports the nurse's suspicion that the client is experiencing fluid volume deficit.

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QLexNursing

1 :
Which action should the nurse take when caring for a client with a tracheostomy?

2 :
Which oxygen delivery device provides a precise amount of oxygen?

3 :
The nurse cares for a client on total parenteral nutrition. What action should the nurse take to prevent complications associated with parenteral nutrition?

4 :
What is the benefit of using a condom catheter over an indwelling urinary catheter for client care?

5 :
The nurse monitors a client who is drinking water. Which assessment finding(s) require follow-up by the nurse? Select all that apply.

6 :
A nurse is preparing to administer a prescribed oral tablet to a client who states, "I have trouble swallowing pills." Which action should the nurse include in the plan of care to promote safe medication administration?

7 :
The nurse is caring for a female client that needs to use the bedpan to urinate. The client cannot bear weight to their lower extremities but does move in the bed well with one-person assist. Place in order the steps the nurse should take to place the client on the bedpan.

8 :
What is the primary benefit of using a spacer with a metered-dose inhaler (MDI) for a child?

9 :
Complete the sentence by choosing from the list of options.

Correct Answers

10 :
The nurse suspects a client is dehydrated. Which urinary assessment finding supports this suspicion?

QLexNursing

1 : Which action should the nurse take when caring for a client with a tracheostomy?

2 : Which oxygen delivery device provides a precise amount of oxygen?

3 : The nurse cares for a client on total parenteral nutrition. What action should the nurse take to prevent complications associated with parenteral nutrition?

4 : What is the benefit of using a condom catheter over an indwelling urinary catheter for client care?

5 : The nurse monitors a client who is drinking water. Which assessment finding(s) require follow-up by the nurse? Select all that apply.

6 : A nurse is preparing to administer a prescribed oral tablet to a client who states, "I have trouble swallowing pills." Which action should the nurse include in the plan of care to promote safe medication administration?

7 : The nurse is caring for a female client that needs to use the bedpan to urinate. The client cannot bear weight to their lower extremities but does move in the bed well with one-person assist. Place in order the steps the nurse should take to place the client on the bedpan.

8 : What is the primary benefit of using a spacer with a metered-dose inhaler (MDI) for a child?

9 : Complete the sentence by choosing from the list of options.

Correct Answers

10 : The nurse suspects a client is dehydrated. Which urinary assessment finding supports this suspicion?

1 :
Which action should the nurse take when caring for a client with a tracheostomy?

2 :
Which oxygen delivery device provides a precise amount of oxygen?

3 :
The nurse cares for a client on total parenteral nutrition. What action should the nurse take to prevent complications associated with parenteral nutrition?

4 :
What is the benefit of using a condom catheter over an indwelling urinary catheter for client care?

5 :
The nurse monitors a client who is drinking water. Which assessment finding(s) require follow-up by the nurse? Select all that apply.

6 :
A nurse is preparing to administer a prescribed oral tablet to a client who states, "I have trouble swallowing pills." Which action should the nurse include in the plan of care to promote safe medication administration?

7 :
The nurse is caring for a female client that needs to use the bedpan to urinate. The client cannot bear weight to their lower extremities but does move in the bed well with one-person assist. Place in order the steps the nurse should take to place the client on the bedpan.

8 :
What is the primary benefit of using a spacer with a metered-dose inhaler (MDI) for a child?

9 :
Complete the sentence by choosing from the list of options.

10 :
The nurse suspects a client is dehydrated. Which urinary assessment finding supports this suspicion?