The nurse is performing tracheostomy care for a client who underwent a laryngectomy for laryngeal cancer. During the procedure, the client begins to cough and is unable to clear the secretions. After the nurse suctions the airway, which finding indicates the intervention was effective?

Absence of coarse crackles.

Increase in respiratory rate.

Increase in breath sounds.

Absence of fine crackles.

Answer and Explanation

The Correct Answer is A

A)   Correct - The absence of coarse crackles indicates that the airway has been cleared of secretions effectively, and the lung sounds are clearer.
B)   Incorrect - An increase in respiratory rate could indicate distress rather than the effectiveness of the intervention.
C)   Incorrect - An increase in breath sounds may not necessarily indicate the effectiveness of the intervention, as the quality of breath sounds matters more than the increase.
D)   Incorrect - The absence of fine crackles might not directly indicate the effectiveness of the intervention, as other factors can influence lung sounds.

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Correct Answer is ["A","B","D","E"]

Explanation

A) Correct - Demonstrating the technique used to monitor blood glucose levels is crucial.

Incorrect technique can lead to inaccurate readings, impacting insulin dosing decisions and blood sugar control.
B) Correct - Some asthma medications, like corticosteroids, can elevate blood glucose levels.

Evaluating the client's asthma medications is essential as they can contribute to fluctuations in blood sugar levels.
C) Incorrect- Asking the client if they want a different manufacturer's glucose monitoring device is not helpful, because it does not address the underlying causes of the poor glycemic control. The client may also perceive this as a lack of confidence in their ability to manage their diabetes or as a criticism of their choice of device. The nurse should focus on educating the client on how to use their current device correctly and consistently, rather than suggesting a change that may not be necessary or feasible.
D) Correct - Understanding the client's daily routine helps identify factors influencing blood glucose control, such as meal timing, activity level, and stress. This information aids in creating a personalized diabetes management plan.
E) Correct - Ensuring the client uses a new insulin needle for each administration is important for preventing infection and complications. Reusing needles can affect injection site health and insulin absorption.

A. Document the client's loss of memory in the record. B. Notify the family of the change in the client's condition. C. Remind the client what day of the week it is. D. Encourage the client to rest during the day.

Correct Answer is C

Explanation

it provides reality orientation and helps the client cope with the change in environment. The client may be experiencing acute confusion or delirium due to stress, medication, infection, or other factors. The PN should remind the client of the date, time, and place frequently and use other strategies such as calendars, clocks, and familiar objects to reduce confusion.

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The nurse is performing tracheostomy care for a client who underwent a laryngectomy for laryngeal cancer. During the procedure, the client begins to cough and is unable to clear the secretions. After the nurse suctions the airway, which finding indicates the intervention was effective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","D","E"]

Explanation

An older female adult who was admited to a long-term care facility yesterday is confused about what day of the week it is. Her history does not indicate that she was confused prior to admission. What action should the practical nurse (PN) take?

Correct Answer is C

Explanation

An elderly client is 12-hours postoperative for a hernia repair and suddenly becomes agitated, staggers out into the corridor, and demands to be set free. After assisting the client back to bed and administering pain medication, which intervention is best for the practical nurse (PN) to implement?

The practical nurse (PN) and unlicensed assistive personnel (UAP) enter a client's room and find the client lying on the bed. The PN determines that the client is unresponsive. Which instruction should the PN give the UAP first?

Find patient data about a client below. After the nurse assesses the client, the physician writes orders. The nurse reviews the orders. Which 2 orders should the nurse complete first?

Which actions should the practical nurse (PN) include when assessing a client for signs and symptoms of ﬂuid volume excess? (Select all that apply.)

An oil retention enema is prescribed for a hospitalized client. The practical nurse (PN) should administer the enema solution at which temperature?

A client is receiving mesalamine 800 mg by mouth three times a day. Which assessment should the nurse perform to assess the effectiveness of the medication?

The practical nurse (PN) prepares to remove a client's saline lock. Which supplies should the PN gather? (Select all that apply.)

When the practical nurse (PN) attempts to assist an 18-year-old client with a mild mental disability to ambulate on the first postoperative day after an appendectomy, she becomes angry and says, "PN, 'Get out of here! I'll get up when I'm ready!" Which response is best for the PN to make?