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Question 1 of 5

A client is to be discharged with a tracheostomy. Which of the following should the nurse most stress when educating the client about home management? Select all that apply.

Correct Answer: B,D

Rationale: Pulmonary hygiene (
B) and tracheostomy care (
D) are critical to prevent infections and maintain airway patency. Bowel care (
A), supplements (
C), and exercise (E) are secondary.

Question 2 of 5

A client has signs of increased intracranial pressure. Which one of the following is an early indicator of deterioration in the client's condition?

Correct Answer: D

Rationale: A decrease in level of consciousness is an early and sensitive indicator of increased intracranial pressure, reflecting cerebral compromise before other signs like pupil changes or vital sign alterations.

Question 3 of 5

Which statement by the parent of a child with sickle cell anemia indicates an understanding of the disease?

Correct Answer: C

Rationale: Extra fluids in summer prevent dehydration, which can trigger sickle cell crises, indicating parental understanding of disease management.

Question 4 of 5

A client with diabetes insipidus is receiving DDAVP (desmopressin acetate). Which lab finding indicates that the medication is having its intended effect?

Correct Answer: B

Rationale: Desmopressin increases water reabsorption, concentrating urine; a urine specific gravity of 1.020 indicates effective treatment.

Question 5 of 5

The nurse is assessing the heart sounds of a client with mitral stenosis following a history of rheumatic fever. To hear a mitral murmur, the nurse should place the stethoscope at:

Correct Answer: D

Rationale: Mitral stenosis murmurs are best heard at the fourth intercostal space midclavicular line, the mitral valve area.

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The nurse is asked by the nurse aide, 'Are peptic ulcers really caused by stress?' The nurse would be correct in replying with the following:

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