NCLEX STYLE QUESTIONS EXAM 4

The nurse is caring for a client diagnosed with a myocardial infarction who is experiencing chest pain. Which interventions to the nurse implement? Select all that apply 1. Administer morphine IM 2. Administer an aspirin PO 3. Apply oxygen via nasal cannula 4. Place the client in a supine position 5. Administer nitroglycerin subcutaneously

2

The client has just returned from a cardiac cath. Which assessment data would warrant immediate intervention from the nurse? 1. The clients blood pressure is 110/70 and the pulse is 90 2. The clients growing dressing is dry and intact 3. The client refuses to keep the leg straight 4. The client denies any numbness and tingling

3

The client who has had a Myocardial infarction is admitted to the telemetry unit from intensive care. Which referral would be most appropriate for the pt? 1. Social worker 2. physical therapy 3. cardiac rehabilitation 4. occupational therapy

3

They diagnosed with rule-out MI Is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first? 1. administer sub lingual nitroglycerin 2. obtain a stat ECG 3. have the client sit down immediately 4. assess the clients vital signs

3

Which assessment should the nurse perform when performing endotracheal suctioning? select all that apply A. closely assess the patient before during and after the procedure B. hyper oxygenate the patient before and after suctioning C. limit the application of suctioning to 20-30 seconds D. monitor patients pulse frequently to detect possible hypoxia and stimulation of the vagus nerve E. use appropriate suction of 80-15 mm Hg F. insert the suction cath no more than 1 cm past the endotracheal tube

ABDE

The nurse is administering a calcium channel blocker to the client diagnosed with a myocardial infarction. Which assessment data would cause the nurse the question administering this medication? 1. apical pulse of 64 2. increased calcium level 3. telemetry with occasional PVC's 4. blood pressure 90/58

4

A patient is diagnosed with hypertension and nadolol (Corgard) is prescribed. The nurse should consult with the health care provider before giving this medication upon finding a history of a. asthma. b. peptic ulcer disease. c. alcohol dependency. d. myocardial infarction (MI).

ANS: A Nonselective β-blockers block β1- and β2-adrenergic receptors and can cause bronchospasm, especially in patients with a history of asthma. β-blockers will have no effect on the patient's peptic ulcer disease or alcohol dependency. β-blocker therapy is recommended after MI.

A nurse is caring for a client with COPD and knows that hypoxia may occur in this patient. What are serious signs of this condition? A. dyspnea B. hypotension C. small pulse pressure D. decreased RR E. pallor F. increased pulse

A C E F

The nurse is reviewing the laboratory tests for a patient who has recently been diagnosed with hypertension. Which result is most important to communicate to the health care provider? a. Serum creatinine of 2.6 mg/dL b. Serum potassium of 3.8 mEq/L c. Serum hemoglobin of 14.7 g/dL d. Blood glucose level of 98 mg/dL

ANS: A The elevated creatinine indicates renal damage caused by the hypertension. The other laboratory results are normal.

Which nursing action should the nurse take first in order to assist a patient with newly diagnosed stage 1 hypertension in making needed dietary changes? a. Have the patient record dietary intake for 3 days. b. Give the patient a detailed list of low-sodium foods. c. Teach the patient about foods that are high in sodium. d. Help the patient make an appointment with a dietitian.

ANS: A The initial nursing action should be assessment of the patient's baseline dietary intake through a 3-day food diary. The other actions may be appropriate, but assessment of the patient's baseline should occur first.

The charge nurse observes a new RN doing discharge teaching for a hypertensive patient who has a new prescription for enalapril (Vasotec). The charge nurse will need to intervene if the new RN tells the patient to a. check the BP with a home BP monitor every day. b. move slowly when moving from lying to standing. c. increase the dietary intake of high-potassium foods. d. make an appointment with the dietitian for teaching.

ANS: C The ACE inhibitors cause retention of potassium by the kidney, so hyperkalemia is a possible adverse effect. The other teaching by the new RN is appropriate for a patient with newly diagnosed hypertension who has just started therapy with enalapril.

Which action will the nurse in the hypertension clinic take in order to obtain an accurate baseline blood pressure (BP) for a new patient? a. Obtain a BP reading in each arm and average the results. b. Deflate the BP cuff at a rate of 5 to 10 mm Hg per second. c. Have the patient sit in a chair with the feet flat on the floor. d. Assist the patient to the supine position for BP measurements.

ANS: C The patient should be seated with the feet flat on the floor. The BP is obtained in both arms, but the results of the two arms are not averaged. The patient does not need to be in the supine position. The cuff should be deflated at 2 to 3 mm Hg per second.

The nurse has just finished teaching a hypertensive patient about the newly prescribed quinapril (Accupril). Which patient statement indicates that more teaching is needed? a. "The medication may not work as well if I take any aspirin." b. "The doctor may order a blood potassium level occasionally." c. "I will call the doctor if I notice that I have a frequent cough." d. "I won't worry if I have a little swelling around my lips and face."

ANS: D Angioedema occurring with angiotensin-converting enzyme (ACE) inhibitor therapy is an indication that the ACE inhibitor should be discontinued. The patient should be taught that if any swelling of the face or oral mucosa occurs, the health care provider should be immediately notified because this could be life threatening. The other patient statements indicate that the patient has an accurate understanding of ACE inhibitor therapy.

Which assessment finding for a patient who is receiving furosemide (Lasix) to treat stage 2 hypertension is most important to report to the health care provider? a. Blood glucose level of 180 mg/dL b. Blood potassium level of 3.0 mEq/L c. Early morning BP reading of 164/96 mm Hg d. Orthostatic systolic BP decrease of 12 mm Hg

ANS: B Hypokalemia is a frequent adverse effect of the loop diuretics and can cause life-threatening dysrhythmias. The health care provider should be notified of the potassium level immediately and administration of potassium supplements initiated. The elevated blood glucose and BP also indicate a need for collaborative interventions but will not require action as urgently as the hypokalemia. An orthostatic drop of 12 mm Hg is common and will require intervention only if the patient is symptomatic.

The client diagnosed with a myocardial infarction asked the nurse, "why do I have to rest and take it easy? My chest doesn't hurt anymore." Which statement would be the nurses best response? 1. Your heart is damaged and needs about 4 to 6 weeks to heal 2. There is a necrotic myocardial tissue that put you at risk for dysrhythmias 3. Your doctor has ordered bedrest therefore you must stay in bed 4. Just because your chest doesn't hurt anymore doesn't mean you are out of danger

1

The client is admitted to the telemetry unit diagnosed with acute exacerbation of congestive heart failure. Which signs and symptoms with the nurse expect when assessing this client? 1. Apical pulse rate of 110 and 4+ pitting edema of the feet 2. thick white sputum and crackles that clear with cough 3. The client sleeping with no pillow and eupnea 4. Radial pulse rate of 90 and CRT less than three seconds

1

The intensive care department nurse is assessing the client who is 12 hours post myocardio infarction. The nurse assesses an S3 heart sound. which intervention should the nurse implement? 1. notify HCP 2. elevate HOB 3. document normal and expected 4. administer morphine IV

1

A nurse is inserting a oropharyngeal airway for a patient who vomits when it is inserted. Which action would be the first that should be taken by the nurse related to this occurrence? A. quickly position pt on the side B. put on disposable gloves and remove airway C. check that the airway is the appropriate size for the pt D. put on sterile gloves and suction the airway

A

What action does the nurse perform to follow safe technique when using a portable o2 cylinder? A check the amount of o2 in the cylinder before using it B. using a cylinder shows that 500 psi is available C. placing the oxygen cylinder on the patient bed D. discontinuing the oxygen cylinder by turning key counterclockwise

A

Along with persistent, crushing chest pain, which signs/symptoms would make the nurse suspect that the client is experiencing a myocardial infarction? 1. Midepigastric pain and pyrosis. 2. Diaphoresis and cool clammy skin. 3. Intermittent claudication and pallor. 4. Jugular vein distention and dependent edema.

2

The client is one-day postop coronary artery bypass surgery. The client complains of chest pain. Which intervention should the nurse implement first? 1. Medicate the client with IV morphine 2. assess the clients chest dressing and vital signs 3. encourage the client to turn from side to side 4. check the clients telemetry monitor

2

The healthcare provider has ordered a ace inhibitor for the client diagnosed with congestive heart failure. Which discharge instructions should the nurse include? 1. Instruct the client to take a cough suppressant if a cough develops 2. Teach the client how to prevent orthostatic hypotension 3. encourage the client to eat bananas to increase potassium level 4. explain the importance of taking medication with food

2

The nurse is developing a nursing care plan for a client diagnosed with congestive heart failure. A nursing diagnosis of "decreased cardiac output related to inability of the heart to pump if effectively" is written. Which short term goal would be best for this client? 1. The client will be able to ambulate in the hall by date of discharge 2. The client will have an audible S1 and S2 with no S3 heard by the end of shift 3. The client will turn cough and deep breathe every two hours 4. The client will have an sp02 reading of 98% by day two of care

2

The nurse is developing a discharge teaching plan for the client diagnosed with congestive heart failure. Which intervention should the nurse include in the plan? Select all that apply. 1. notify the HCP of a weight gain of more than 1 pound in a week 2. Teach the client how to count the radial pulse went taking digoxin, a cardiac glycoside 3. instruct the client to remove the salt shaker from the dinner table 4. encourage the client to monitor urine output for a change in color to become dark 5. Discuss the importance of taking the loop diuretic for furosemide at bedtime

2&3

The charge nurse is making shift assignments for the medical floor. Which client should the nurse assign to the most experienced registered nurse? 1. The client diagnosed with CHF failure who is being Discharged in the morning 2. the client who is happy having frequent in continent liquid bowel movements and vomiting 3. the client with an apical pulse rate of 116 and a respiratory rate of 26 a blood pressure of 94/60 4. the client who is complaining of chest pain on inspiration in a nonproductive cough

3

The client diagnosed with a myocardial infarction is on bed rest. The tech is encouraging the client to move his legs. Which action should the nurse implement? 1. Instruct the tech to stop encouraging the leg movements 2. report this behavior to the charge nurse 3. praise the tech for encouraging the client to move the legs 4. take no action concerning the techs behavior

3

The client diagnosed with a myocardial infarction is six hours post-op right femoral percutaneous transluminal coronary angioplasty, Also known as balloon surgery. Which assessment data would require immediate intervention by the nurse? 1. The client is keeping the affected extremity straight 2. The pressure dressing to the right femoral area is intact 3. The client is complaining of numbness in the right foot 4. The clients right pedal pulse is 3+ and bounding

3

The nurse is assessing the client diagnosed with congestive heart failure. Which signs and symptoms would indicate that the medical treatment has been effective? 1. The clients peripheral pitting edema has gone from 3+ to 4+ 2. The client is able to take the radial pulse accurately 3. The client is able to perform ADLs without dyspnea 4. The client has minimal jugular vein distention

3

Which cardiac enzyme with the nurse expect to elevate first in a client diagnosed with an MI? 1. Creatinine kinase 2. LDH 3. Troponin 4. White blood cell count

3

Which BP finding by the nurse indicates that no changes in therapy are needed for a patient with stage 1 hypertension who has a history of heart failure? a. 108/64 mm Hg b. 128/76 mm Hg c. 140/90 mm Hg d. 136/ 82 mm Hg

ANS: B The goal for antihypertensive therapy for a patient with hypertension and heart failure is a BP of <130/80 mm Hg. The BP of 108/64 may indicate overtreatment of the hypertension and an increased risk for adverse drug effects. The other two blood pressures indicate a need for modifications in the patient's treatment.

The nurse in the emergency department received change-of-shift report on four patients with hypertension. Which patient should the nurse assess first? a. 52-year-old with a BP of 212/90 who has intermittent claudication b. 43-year-old with a BP of 190/102 who is complaining of chest pain c. 50-year-old with a BP of 210/110 who has a creatinine of 1.5 mg/dL d. 48-year-old with a BP of 200/98 whose urine shows microalbuminuria

ANS: B The patient with chest pain may be experiencing acute myocardial infarction and rapid assessment and intervention is needed. The symptoms of the other patients also show target organ damage, but are not indicative of acute processes.

The nurse and the tech are caring for four clients on a telemetry unit. Which nursing test would be best for the nurse to delegate to the tech? 1. Assist the client to go down to the smoking area for a cigarette 2. transport the client to the ICU via stretcher 3. provide the client going home discharge teaching instructions 4. help position the client who is having a portable x-ray done

4

The nurse enters the room of a client diagnosed with congestive heart failure. The client is lying in bed grasping for breath, is cool and clammy, and has buccal cyanosis. Which intervention with the nurse implement first? 1. Sponge the clients forehead 2. obtain a pulse oximetry 3. take vital signs 4. assist client in sitting position

4

The nurse has written an outcome goal "demonstrates tolerance for increased activity" for a client diagnosed with congestive heart failure. Which intervention should the nurse implement to assist the client to achieve this outcome? 1. Measure intake and output. 2. Provide two (2)-g sodium diet. 3. Weigh client daily. 4. Plan for frequent rest periods.

4

The nurse is assessing a patient who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider? a. Urine output over 8 hours is 200 mL less than the fluid intake. b. The patient is unable to move the left arm and leg when asked to do so. c. Tremors are noted in the fingers when the patient extends the arms. d. The patient complains of a severe headache with pain at level 8/10 (0 to 10 scale).

ANS: B The patient's inability to move the left arm and leg indicates that a hemorrhagic stroke may be occurring and will require immediate action to prevent further neurologic damage. The other clinical manifestations also likely are caused by the hypertension and will require rapid nursing actions, but they do not require action as urgently as the neurologic changes.

The nurse obtains this information from a patient with prehypertension. Which finding is most important to address with the patient? a. Low dietary fiber intake b. No regular aerobic exercise c. Weight 5 pounds above ideal weight d. Drinks wine with dinner once a week

ANS: B The recommendations for preventing hypertension include exercising aerobically for 30 minutes most days of the week. A weight that is 5 pounds over the ideal body weight is not a risk factor for hypertension. The Dietary Approaches to Stop Hypertension (DASH) diet is high in fiber, but increasing fiber alone will not prevent hypertension from developing. The patient's alcohol intake will not increase the hypertension risk.

The nurse is assessing the contact us with congestive heart failure, which laboratory data would indicate that the client is in severe congestive heart failure? 1. And elevated BNP 2. an elevated CK - MB 3. a positive d-dimer 4. a positive ventilation/perfusion VQ scan

1

the nurse on the telemetry unit has just received an a.m. shift report. Which client should the nurse assessed first? 1. The client diagnosed with a myocardial infarction who has a audible S3 heart sound 2. The client diagnosed with congestive heart failure who has 4+ sacral pitting edema 3. The client diagnosed with pneumonia who has a pulse ox reading of 94%

1

Which action will be included in the plan of care when the nurse is caring for a patient who is receiving sodium nitroprusside (Nipride) to treat a hypertensive emergency? a. Organize nursing activities so that the patient has undisturbed sleep for 6 to 8 hours at night. b. Assist the patient up in the chair for meals to avoid complications associated with immobility. c. Use an automated noninvasive blood pressure machine to obtain frequent BP measurements. d. Place the patient on NPO status to prevent aspiration caused by nausea and the associated vomiting.

ANS: C Frequent monitoring of BP is needed when the patient is receiving rapid-acting IV antihypertensive medications. This can be most easily accomplished with an automated BP machine or arterial line. The patient will require frequent assessments, so allowing 6 to 8 hours of undisturbed sleep is not appropriate. When patients are receiving IV vasodilators, bed rest is maintained to prevent decreased cerebral perfusion and fainting. There is no indication that this patient is nauseated or at risk for aspiration, so an NPO status is unnecessary.

A patient has been diagnosed with possible white coat hypertension. Which action will the nurse plan to take next? a. Schedule the patient for frequent BP checks in the clinic. b. Instruct the patient about the need to decrease stress levels. c. Tell the patient how to self-monitor and record BPs at home. d. Teach the patient about ambulatory blood pressure monitoring.

ANS: C Having the patient self-monitor BPs at home will provide a reliable indication about whether the patient has hypertension. Frequent BP checks in the clinic are likely to be high in a patient with white coat hypertension. Ambulatory blood pressure monitoring may be used if the data from self-monitoring is unclear. Although elevated stress levels may contribute to hypertension, instructing the patient about this is unlikely to reduce BP.

Which information should the nurse include when teaching a patient with newly diagnosed hypertension? a. Dietary sodium restriction will control BP for most patients. b. Most patients are able to control BP through lifestyle changes. c. Hypertension is usually asymptomatic until significant organ damage occurs. d. Annual BP checks are needed to monitor treatment effectiveness.

ANS: C Hypertension is usually asymptomatic until target organ damage has occurred. Lifestyle changes and sodium restriction are used to help manage blood pressure, but drugs are needed for most patients. BP should be checked by the health care provider every 3 to 6 months.

The RN is caring for a patient with a hypertensive crisis who is receiving sodium nitroprusside (Nipride). Which of the following nursing actions can the nurse delegate to an experienced LPN/LVN? a. Titrate nitroprusside to maintain BP at 160/100 mm Hg. b. Evaluate effectiveness of nitroprusside therapy on BP. c. Set up the automatic blood pressure machine to take BP every 15 minutes. d. Assess the patient's environment for adverse stimuli that might increase BP.

ANS: C LPN/LVN education and scope of practice include correct use of common equipment such as automatic blood pressure machines. The other actions require more nursing judgment and education and should be done by RNs.

After giving a patient the initial dose of oral labetalol (Normodyne) for treatment of hypertension, which action should the nurse take? a. Encourage oral fluids to prevent dry mouth or dehydration. b. Instruct the patient to ask for help if heart palpitations occur. c. Ask the patient to request assistance when getting out of bed. d. Teach the patient that headaches may occur with this medication.

ANS: C Labetalol decreases sympathetic nervous system activity by blocking both α- and β-adrenergic receptors, leading to vasodilation and a decrease in heart rate, which can cause severe orthostatic hypotension. Heart palpitations, dehydration, and headaches are possible side effects of other antihypertensives.

A patient with a history of hypertension treated with a diuretic and an angiotensin-converting enzyme (ACE) inhibitor arrives in the emergency department complaining of a severe headache and has a BP of 240/118 mm Hg. Which question should the nurse ask first? a. Did you take any acetaminophen (Tylenol) today? b. Do you have any recent stressful events in your life? c. Have you been consistently taking your medications? d. Have you recently taken any antihistamine medications?

ANS: C Sudden withdrawal of antihypertensive medications can cause rebound hypertension and hypertensive crisis. Although many over-the-counter medications can cause hypertension, antihistamines and acetaminophen do not increase BP. Stressful events will increase BP but not usually to the level seen in this patient.

During change-of-shift report, the nurse obtains this information about a hypertensive patient who received the first dose of propranolol (Inderal) during the previous shift. Which information indicates that the patient needs immediate intervention? a. The patient's most recent BP reading is 156/94 mm Hg. b. The patient's pulse has dropped from 64 to 58 beats/minute. c. The patient has developed wheezes throughout the lung fields. d. The patient complains that the fingers and toes feel quite cold.

ANS: C The most urgent concern for this patient is the wheezes, which indicate that bronchospasm (a common adverse effect of the noncardioselective β-blockers) is occurring. The nurse should immediately obtain an oxygen saturation measurement, apply supplemental oxygen, and notify the health care provider. The mild decrease in heart rate and complaint of cold fingers and toes are associated with β-receptor blockade but do not require any change in therapy. The BP reading may indicate that a change in medication type or dose may be indicated; however, this is not as urgently needed as addressing the bronchospasm.

A 52-year-old patient who has no previous history of hypertension or other health problems suddenly develops a BP of 188/106 mm Hg. After reconfirming the BP, it is appropriate for the nurse to tell the patient that a. a BP recheck should be scheduled in a few weeks. b. the dietary sodium and fat content should be decreased. c. there is an immediate danger of a stroke and hospitalization will be required. d. more diagnostic testing may be needed to determine the cause of the hypertension.

ANS: D A sudden increase in BP in a patient over age 50 with no previous hypertension history or risk factors indicates that the hypertension may be secondary to some other problem. The BP will need rapid treatment and ongoing monitoring. If the patient has no other risk factors, a stroke in the immediate future is unlikely. There is no indication that dietary salt or fat intake have contributed to this sudden increase in BP, and reducing intake of salt and fat alone will not be adequate to reduce this BP to an acceptable level.

When a patient with hypertension who has a new prescription for atenolol (Tenormin) returns to the health clinic after 2 weeks for a follow-up visit, the BP is unchanged from the previous visit. Which action should the nurse take first? a. Provide information about the use of multiple drugs to treat hypertension. b. Teach the patient about the reasons for a possible change in drug therapy. c. Remind the patient that lifestyle changes also are important in BP control. d. Question the patient about whether the medication is actually being taken.

ANS: D Since noncompliance with antihypertensive therapy is common, the nurse's initial action should be to determine whether the patient is taking the atenolol as prescribed. The other actions also may be implemented, but these would be done after assessing patient compliance with the prescribed therapy.

After the nurse teaches the patient with stage 1 hypertension about diet modifications that should be implemented, which diet choice indicates that the teaching has been effective? a. The patient avoids eating nuts or nut butters. b. The patient restricts intake of dietary protein. c. The patient has only one cup of coffee in the morning. d. The patient has a glass of low-fat milk with each meal.

ANS: D The Dietary Approaches to Stop Hypertension (DASH) recommendations for prevention of hypertension include increasing the intake of calcium-rich foods. Caffeine restriction and decreased protein intake are not included in the recommendations. Nuts are high in beneficial nutrients and 4 to 5 servings weekly are recommended in the DASH diet.

A patient has just been diagnosed with hypertension and has a new prescription for captopril (Capoten). Which information is important to include when teaching the patient? a. Check BP daily before taking the medication. b. Increase fluid intake if dryness of the mouth is a problem. c. Include high-potassium foods such as bananas in the diet. d. Change position slowly to help prevent dizziness and falls.

ANS: D The angiotensin-converting enzyme (ACE) inhibitors frequently cause orthostatic hypotension, and patients should be taught to change position slowly to allow the vascular system time to compensate for the position change. Increasing fluid intake may counteract the effect of the medication, and the patient is taught to use gum or hard candy to relieve dry mouth. The BP does not need to be checked at home by the patient before taking the medication. Because ACE inhibitors cause potassium retention, increased intake of high-potassium foods is inappropriate.

A nurse is choosing a cath to use to suction a patient endotracheal tube via an open system. On which factor would the nurse decide the size of the cath to use? A. age of the pt B. the size of the endotracheal tube C. the type of secretions suctioned D. the height and weight of pt

B

A nurse is providing postural drainage for a patient with cystic fibrosis. In which position should the nurse place the patient to drain the right lobe of the lung? A. high fowlers B. left side with pillow under chest wall C. lying position, 1/2 on abdomen and half on side D. trendelenberg

B

When planning care for the patient with chronic lung disease who is receiving o2 through a nasal cannula, what does the nurse expect? A. the o2 must be humidified B. the rate will be no more than 2-3 L/min or less C. ABG's will be drawn every 4 hours D. the flow rate will be ^ L/min or more

B

A nurse is caring for a 16 year old pt who has been hospitalized for an acute asthma exacerbation. Which testing methods may the nurse use to measure the patients o2 saturation? select all that apply A. thoracentesis B. spirometry C. pulse oximetry D. peak expiratory flow rate E. diffusion capacity F. maximal respiratory pressure

B C D

A nurse working in a long term care unit is providing teaching for the client with altered oxygenation due to COPD or asthma. Which measures would the nurse recommend? select all that apply A. refrain from exercise B. reduce anxiety C. eat meals 1-2 hrs before bronchodilators D. eat high protein high calorie diet E. maintain a high fowlers position when possible F. drink 2-3 pints of clear fluids daily

B D E

A nurse is securing a patient endotracheal tube with tape and observes that the tube depth changed during the reaping. Which action would be appropriate related to this incident? A. instruct assistant to notify HCp B. assess vital signs C. remove tape and adjust the depth to ordered depth and reapply tape D. no action required the depth will fix itself

C

A patient with COPD is unable to perform ADL's without becoming exhausted. Which nursing diagnosis describes this alteration in oxygenation as the etiology? A. decreased cardiac output related to difficulty breathing B. impaired gas exchange related to the use of bronchodilators C. fatigue related to impaired oxygen transport system D. ineffective airway clearance related to fatigue

C

A nurse is teaching a patient how to use a metered dose inhaler for her asthma. Which comments from the pt assure the nurse that teaching has been effective? select all that apply A. I will be careful not to shake up the canister before use B. I will hold the canister upside down when using it C. I will inhale the medication through my nose D. I will continue to inhale when the cold replant is in my throat E I will only inhale one spray with one breath F. I will activate the device while continuing to inhale

DCF

A nurse is suctioning a nasopharyngeal airway of a patient to maintain a patent airway. For which condition would the nurse anticipate the need for a nasal trumpet? a.) the pt vomits during suction b.) the secretions appear to be in the stomach contents c.) the cath touches an unsterile surface d.) epistaxis is noted with continued suctioning

d