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A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take?

Lubricate the suction catheter tip with sterile saline

Suction two to three times with a 50-second pause between passes

Hyperventilate the client on 100% oxygen prior to suctioning

Perform chest physiotherapy prior to suctioning

None

Answer and Explanation

The Correct Answer is C

Correct Answer: B. Position the sterile drape leaving the perineum exposed.

Rationales

A. Lubricate the catheter with water-soluble gel.
Lubrication is important to reduce urethral trauma, but this is not the first step once the sterile field is prepared. It comes after draping and cleansing, just before catheter insertion.

B. Position the sterile drape leaving the perineum exposed.
This is the first action after donning sterile gloves and preparing the field. Draping maintains a sterile environment and provides access to the insertion site. Ensuring sterility from the beginning is critical for preventing catheter-associated infections.

C. Cleanse the client’s meatus with antiseptic solution.
Cleansing the meatus is done after draping to reduce the risk of introducing microorganisms during catheter insertion. Although essential, it is not the very first step once the sterile procedure begins.

D. Attach a prefilled syringe to the catheter inflation hub.
The balloon should not be prepared or inflated until after the catheter has been inserted and urine return is observed. Attaching the syringe too early may risk accidental inflation outside the bladder.

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Correct Answer is B

Explanation

A. "There is no way to predict how long it will last in each individual client." This response acknowledges the variability among individuals but does not provide specific information about urinary frequency during pregnancy. While it's true that the duration of urinary frequency can vary from person to person, the response lacks guidance or reassurance for the client.
B. "It occurs during the first trimester and near the end of the pregnancy." This response correctly identifies the pattern of urinary frequency during pregnancy. Urinary frequency is common during the first trimester due to hormonal changes and the growing uterus pressing on the bladder. It may also occur near the end of pregnancy as the fetus descends into the pelvis, putting pressure on the bladder again.
C. "In most cases it only lasts until the 12th week, but it will continue if you have poor bladder tone." This response suggests that urinary frequency typically resolves by the 12th week of pregnancy but may persist if the client has poor bladder tone. While urinary frequency may improve for some women after the first trimester, attributing its continuation solely to poor bladder tone oversimplifies the issue.
D. "It’s a minor inconvenience, which you should ignore." This response minimizes the client's concerns and does not provide helpful information about urinary frequency during pregnancy. Urinary frequency can be distressing for some pregnant individuals and should not be dismissed as a minor inconvenience.

A. Bleeding B. Cataracts C. Dysrhythmias D. Pancreatitis

Correct Answer is C

Explanation

A. Bleeding: While haloperidol can rarely cause agranulocytosis, which may lead to bleeding, it is not a common adverse effect associated with the medication. However, clients taking antipsychotic medications like haloperidol should be monitored for any signs of bleeding, such as petechiae or bruising.
B. Cataracts: Haloperidol is not typically associated with the development of cataracts. However, long-term use of certain antipsychotic medications, including haloperidol, may increase the risk of developing metabolic side effects such as weight gain and dyslipidemia, which could indirectly contribute to the risk of cataract formation.
C. Dysrhythmias: This is the correct answer. Haloperidol has the potential to prolong the QT interval, leading to a type of dysrhythmia known as torsade’s de pointes. Therefore, clients taking haloperidol should be monitored for signs of QT prolongation, such as palpitations, syncope, or sudden cardiac arrest.
D. Pancreatitis: While rare, haloperidol has been associated with pancreatitis as a potential adverse effect. However, dysrhythmias are a more common and immediate concern, especially with acute administration or in clients with predisposing factors for QT prolongation, such as electrolyte imbalances or concurrent use of other medications known to prolong the QT interval.

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A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take?

Correct Answer: B. Position the sterile drape leaving the perineum exposed.

Rationales

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary frequency and asks if this will continue until delivery. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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