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Questions 160

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Question 1 of 5

Which assessment findings provide the nurse with the best indications that a client's tracheostomy needs suctioning? Select all that apply.

Correct Answer: C,E,F

Rationale: Noisy respirations, coughing up sputum, and a low pulse oximeter reading (87%) indicate airway obstruction or secretions that require suctioning. A slowed pulse rate, cool/moist skin, and elevated respiratory rate are not specific indicators for suctioning.

Question 2 of 5

Which statement provides the best indication that a client understands the nurse's teaching about alprazolam (Xanax), a newly prescribed medication?

Correct Answer: A

Rationale: Alcohol can potentiate alprazolam's sedative effects, increasing the risk of adverse events, so avoiding it indicates understanding.

Question 3 of 5

While visiting a client who takes a prescribed diuretic, how can a home health care nurse best evaluate the drug's effectiveness?

Correct Answer: A

Rationale: Diuretics reduce fluid retention, leading to weight loss. Monitoring weight is the best way to evaluate their effectiveness.

Question 4 of 5

At the time of a retinal detachment, the client will most likely experience which effects? Select all that apply.

Correct Answer: A,F

Rationale: Retinal detachment causes flashes of light due to retinal traction and wavy vision (floaters or curtain-like vision) due to retinal separation. Severe pain or inability to see light is not typical.

Question 5 of 5

What is the best evidence that a postpartum client's Kegel exercises are effective?

Correct Answer: D

Rationale: Effective Kegel exercises strengthen pelvic floor muscles, allowing the client to control urine flow, indicating success.

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