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Question 1 of 5

The nurse is caring for a client with a permanent tracheostomy who is able to eat. Which is the correct action by the nurse in managing this tube?

Correct Answer: D

Rationale: Deflating the cuff during meals allows normal swallowing, reducing aspiration risk, and is maintained for 1 hour post-meal.

Question 2 of 5

The nurse assesses a client complaining of a headache. When the nurse shines a light on the frontal and maxillary sinuses, the light does not penetrate the tissues. What is the best interpretation of this finding?

Correct Answer: C

Rationale: Lack of light penetration during transillumination suggests fluid or pus in the sinuses, indicating a potential infection or obstruction.

Question 3 of 5

A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is:

Correct Answer: C

Rationale: Post-tonsillectomy, the risk of bleeding and aspiration is a priority due to the surgical site in the throat.

Question 4 of 5

A pregnant woman has experienced repeated vaginal monilial infections. When educating the client about the infection, which information should the nurse include? Select all that apply.

Correct Answer: A,B,C

Rationale: Daily bathing (
A), understanding estrogen's role in yeast growth (
B), and wearing cotton panties (
C) help manage monilial infections. Panty liners (
D) may trap moisture, and avoiding panties (E) is impractical.

Question 5 of 5

The nurse is caring for a client who is postoperative day 1 following a mastectomy. The client refuses to look at the surgical site or participate in wound care teaching. Which of the following actions by the nurse is MOST appropriate?

Correct Answer: A

Rationale: encouraging the client to express feelings promotes coping and addresses potential body image concerns

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