Rapid Fire Quick Set NCLEX

Lumbar Puncture Position

Side-lying with the legs pulled up and the head bent down onto the chest

The nurse is preparing to care for a client who will be weaned from a cuffed tracheostomy tube. The nurse is planning to use a tracheostomy plug and plans to insert it into the opening in the outer cannula. Which nursing action is required before plugging the tube? 1 Deflate the cuff on the tube. 2Place the inner cannula into the tube. 3Ensure that the client is able to speak. 4Ensure that the client is able to swallow.

1 Deflate the cuff on the tube. Rationale:Plugging a tracheostomy tube is usually done by inserting the tracheostomy plug (decannulation stopper) into the opening of the outer cannula. This closes off the tracheostomy, and airflow and respiration occur normally through the nose and mouth. When plugging a cuffed tracheostomy tube, the cuff must be deflated. If it remains inflated, ventilation cannot occur, and respiratory arrest could result. A tracheostomy plug could not be placed in a tracheostomy if an inner cannula was in place. The ability to swallow or speak is unrelated to weaning and plugging the tube.

The nurse is preparing to discontinue a client's nasogastric tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Before removing the tube, the nurse would make which statement to the client? 1 Take a deep breath when I tell you, and hold it while I remove the tube. 2 Take a deep breath when I tell you, and bear down while I remove the tube. 3 Take a deep breath when I tell you, and slowly exhale while I remove the tube. 4 Take a deep breath when I tell you, and breathe normally while I remove the tube."

1 Take a deep breath when I tell you, and hold it while I remove the tube. Rationale:The client would take a deep breath, because the client's airway will be temporarily obstructed during tube removal. The client is then told to hold the breath and the tube is withdrawn slowly and evenly over the course of 3 to 6 seconds (coil the tube around the hand while removing it) while the breath is held. Bearing down could inhibit the removal of the tube. Exhaling is not possible during removal because the airway is temporarily obstructed during removal. Breathing normally could result in aspiration of gastric secretions during inhalation.

The nurse recognizes that which interventions are likely to facilitate effective communication between a dying client and family? Select all that apply. 1The nurse encourages the client and family to identify and discuss feelings openly. 2The nurse assists the client and family in carrying out spiritually meaningful practices. 3The nurse removes autonomy from the client to alleviate any unnecessary stress for the client. 4The nurse makes decisions for the client and family to relieve them of unnecessary demands. 5The nurse maintains a calm attitude and one of acceptance when the family or client expresses anger.

1,2,5

The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal chamber. Which is the most appropriate nursing action? 1. Check for an air leak. 2Document the findings. 3Notify the primary health care provider. 4Change the chest tube drainage system.

2Document the findings. Rationale:Bubbling in the water seal chamber is caused by air passing out of the pleural space into the fluid in the chamber. Intermittent (not constant) bubbling is normal. It indicates that the system is accomplishing one of its purposes, removing air from the pleural space. Continuous bubbling during inspiration and expiration indicates that an air leak exists. If this occurs, it must be corrected. Notifying the primary health care provider and changing the chest tube drainage system are not indicated at this time.

A client with tuberculosis whose status is being monitored in an ambulatory care clinic asks the nurse when it is permissible to return to work. What factor would the nurse include when responding to the client? 1 Five blood cultures are negative. 2Three sputum cultures are negative. 3A blood culture and a chest x-ray are negative. 4A sputum culture and a tuberculin skin test are negative.

2Three sputum cultures are negative. Rationale:The client with tuberculosis must have sputum cultures performed every 2 to 4 weeks after initiation of antituberculosis medication therapy. The client may return to work when the results of three sputum cultures are negative, because the client is considered noninfectious at that point. Options 1, 3, and 4 are not reliable determinants of a noninfectious status.

A home care nurse is visiting a client to provide follow-up evaluation and care of a leg ulcer. On removing the dressing from the leg ulcer, the nurse notes that the ulcer is pale and deep and that the surrounding tissue is cool to the touch. The nurse would document that these findings identify which type of ulcer? 1 A stage 1 ulcer 2 A vascular ulcer 3 An arterial ulcer 4 A venous stasis ulcer

3 - An arterial ulcer Rationale:Arterial ulcers have a pale deep base and are surrounded by tissue that is cool with trophic changes such as dry skin and loss of hair. Arterial ulcers are caused by tissue ischemia from inadequate arterial supply of oxygen and nutrients. A stage 1 ulcer indicates a reddened area with an intact skin surface. A venous stasis ulcer (vascular) has a dark red base and is surrounded by brown skin with local edema. This type of ulcer is caused by the accumulation of waste products of metabolism that are not cleared, as a result of venous congestion.

A client with terminal cancer arrives at the emergency department dead on arrival (DOA). After an autopsy is prescribed, the client's family requests that no autopsy be performed. Which response to the family is most appropriate? 1The decision is made by the medical examiner. 2An autopsy is mandatory for any client who is DOA. 3I will contact the medical examiner regarding your request. 4It is required by federal law. Tell me why you don't want the autopsy done."

3 -I will contact the medical examiner regarding your request. Rationale: An autopsy is required by state law in certain circumstances, including the sudden death of a client and a death that occurs under suspicious circumstances. A client may have provided oral or written instructions regarding an autopsy after death. If an autopsy is not required by law, these oral or written requests will be granted. If no oral or written instructions were provided, state law determines who has the authority to consent for an autopsy. Most often, the decision rests with the surviving relative or next of kin.

A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse would assess the client for which signs and symptoms characteristic of this disorder? 1 Bradycardia and hyperactivity 2 Decreased respiratory rate and depth 3 Headache, restlessness, and confusion 4Bradypnea, dizziness, and paresthesias

3 Headache, restlessness, and confusion Rationale:When a client is experiencing respiratory acidosis, the respiratory rate and depth increase in an attempt to compensate. The client also experiences headache; restlessness; mental status changes, such as drowsiness and confusion; visual disturbances; diaphoresis; cyanosis as the hypoxia becomes more acute; hyperkalemia; rapid, irregular pulse; and dysrhythmias. Options 1, 2, and 4 are not specifically associated with this disorder.

The nurse in the medical unit is assigned to provide discharge teaching to a client with a diagnosis of angina pectoris. The nurse is discussing lifestyle changes that are needed to minimize the effects of the disease process. The client continually changes the subject during the teaching session. The nurse interprets that this client's behavior is most likely related to which problem? 1Anxiety related to the need to make lifestyle changes 2Boredom resulting from having already learned the material 3An attempt to ignore or deny the need to make lifestyle changes 4Lack of understanding of the material provided at the teaching session and embarrassment about asking questions

3. An attempt to ignore or deny the need to make lifestyle changes Rationale:Denial is a defense mechanism that allows the client to minimize a threat that may be manifested by refusal to discuss what has happened. Denial is a common early reaction associated with chest discomfort, angina, or myocardial infarction (MI). Anxiety usually is manifested by symptoms of sympathetic nervous system arousal. No data are provided in the question that would lead the nurse to interpret the client's behavior as boredom or as either understanding or not understanding the material provided at the teaching session.