NCLEX-PN

Correct Response : C Explanation : A sputum culture should be collected with the absence of saliva. The sputum should be cleared from the upper airway with a deep cough that is performed after a deep breath is taken. (See Sputum Specimen Collection ) 4.​ Your client has a cuffed tracheostomy tube that now needs suctioning. You prepare and preoxygenate the client and have lubricated the tip of the suction catheter with a water-soluble jelly. As you insert the suction catheter, you reach a point of resistance. What should you do first?

A.​ Inflate the cuff if the cuff is deflated B.​ Deflate the cuff if the cuff is inflated C.​ Remove the inner cannula of the tube D.​ Call the doctor about this airway obstruction Correct Response : B

Explanation : The first thing that you should do when you insert the suction catheter and you reach a point of resistance is to deflate the cuff when it is inflated, and the second thing that you should do is to remove the inner cannula and suction out the mucus plug. You would not call the doctor because there is an airway obstruction; you should correct this problem with the measures above (See Maintaining Tube Patency ) 5.​ The Norton Scale measures: A.​ The level of pain among school-age children B.​ The risk for impairment of skin integrity C.​ Levels of muscular strength D.​ Levels of mobility Correct Response : B Explanation : The Norton Scale and the Braden Scale are standardized tools to screen clients for their risk of skin breakdown, pressure ulcers and an impairment of skin integrity. Pain levels among school-age children are measured with other standardized pain tools for pediatric clients, and levels of muscular strength and mobility are measured also with other standardized tests and not the Norton Scale. (See Assessment of Skin Breakdown Risk ) 6.​ Select the client who is at the greatest risk for the development of cancer:

A.​ A 76-year-old female client who has a history of alcohol abuse B.​ A 76-year-old female client who has a history of diabetes C.​ A 64-year-old male client who has a history of impaired oxygen transport D.​ A 64-year-old male client who has hypotension Correct Response: A

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