Kaplan NCLEX Readiness
Exam Flashcards |
Quizlet 2023/2024
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Kaplan NCLEX Readiness Exam
Terms in this set (180)
The nurse cares for a client1) CORRECT - Implementation: outcome desired; with a cuffed
tracheostomycuff inflation decreases the risk of aspiration; cuff tube. Before performing
oralposition and pressure should be assessed care, the nurse notes that thefrequently;
swallowing and breathing will cause
client's tracheostomy cuff istracheostomy tube movement inflated.
Which of the following is the MOST appropriate action2) Implementation:
outcome not desired;
for the nurse to take? accumulated oral secretions above the cuff will
drain into the bronchi; increased risk of infection
1. Leave the cuff inflated and suction through the3) Implementation: outcome not
desired; cuff tracheostomy. pressure should be less than 20 mm Hg (25 cm
2. Deflate the cuff and suctionH2O); risk of trauma to trachea with higher
through the tracheostomypressures tube.
3. Inflate the cuff pressure to4) Implementation: outcome not desired; increases 40
mm Hg before suctioning. the risk of trauma to lower airways
4. Adjust the wall suctionpressure to 160 to 180 mm Hg before suctioning.
A young adult brings a friend1) Assessment: outcome not priority but may be to the
emergency departmentappropriate; pinpoint pupils are a sign of heroin and states that the
friend hasoverdose been using heroin. Which
action by the nurse is the2) CORRECT - Assessment: outcome priority;
MOST appropriate? shallow respirations seen; impaired alveolar gas
exchange and possible respiratory arrest
1. Assess pupil size and reactivity. 3) Assessment: outcome not priority; most
2. Assess oxygen saturationimpo
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