The nurse is suctioning a client through a tracheal tube. During the procedure, the nurse notes on the cardiac monitor that the heart rate has dropped 10 beats. Which should be the nurse's next action?

Correct Answer: B

Rationale: A 10-beat heart rate drop during suctioning suggests vagal stimulation or hypoxia; stopping the procedure and oxygenating (B) is the next action to reverse this. Notifying the RN (A) or limiting time (D) follows. Continuing (C) risks worsening. B is correct. Rationale: Suctioning can trigger bradycardia via vagal nerve activation or oxygen depletion; halting and oxygenating restores stability, a critical step per airway management guidelines, preventing further cardiac compromise.

Correct Answer: C

Rationale: Abdominal distention needs inspection (e.g., bloating) and percussion (e.g., tympany for gas) unlike inspection alone or palpation (tenderness). Nurses use e.g., tap for cause, per assessment.

Correct Answer: B

Rationale: Tracheoesophageal fistula (TEF), a rare tracheostomy complication, involves an abnormal connection between trachea and esophagus. Aspiration of gastric contents during suctioning (B) is a definitive sign, indicating esophageal leakage into the airway. Frequent suctioning (A) or excessive secretions (D) are nonspecific. Pink skin (C) reflects good oxygenation, not TEF. B is correct. Rationale: TEF allows gastric contents to enter the trachea, detected during suctioning, requiring urgent intervention like tube adjustment or surgery, distinct from routine secretion issues, per critical care nursing.

Correct Answer: A

Rationale: Illness behavior is how people react when sick (A), per sociology e.g., seeking care. Prevention (B) and treatment (C) are separate, not all (D). A truly defines illness response, making it correct.

Correct Answer: A

Rationale: Informing the doctor of Mr. Gary's refusal is advocacy (A) upholding his rights, per nursing. Fidelity (B) promises, veracity (C) truth, justice (D) fairness not refusal-based. A supports autonomy, making it correct.

Correct Answer: B

Rationale: The correct answer is B: 'You should decrease your intake of potassium-rich foods.' Hyperkalemia is a condition characterized by excess potassium in the blood. To manage hyperkalemia effectively, it is crucial to reduce the intake of potassium-rich foods. This helps in lowering the overall potassium levels in the body and prevents complications associated with hyperkalemia. Choices A, C, and D are incorrect. Increasing the intake of potassium-rich foods (Choice A) would exacerbate hyperkalemia. Avoiding foods that contain lactose (Choice C) is not directly related to managing hyperkalemia. Increasing the intake of dairy products (Choice D) is not recommended as they can be a significant source of dietary potassium.

Correct Answer: A

Rationale: Relapsing fever spikes (39.5-40°C) with normal breaks (36.5°C) e.g., borrelia, days apart. Intermittent (daily normal), remittent (fluctuating high), and constant (stable) differ. Nurses note this e.g., two-day gap for infection management, per fever types.

Correct Answer: B

Rationale: Widening pulse pressure (e.g., 140/60) indicates rising intracranial pressure post-head injury, reflecting Cushing's triad with bradycardia and respiratory changes pulse, respiration, or mild fever alone don't confirm this. Nurses report this, signaling brain herniation risk, necessitating urgent intervention like mannitol or surgery.

Correct Answer: C

Rationale: Coping responds to stress (A), can be adaptive/maladaptive (B), may solve problems (D) 'always solves' (C) isn't true, as some coping (e.g., denial) avoids, per Lazarus. C's certainty fails, making it untrue.