Question

1. A nurse is suctioning the airway of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following findings should the nurse identify as an indication that the suctioning has been effective?
   1. Presence of productive cough
   2. Flattening of the artificial airway cuff
   3. Thinning of mucous secretions
   4. Decreased peak inspiratory pressure
2. A nurse is performing a gait assessment on a client to evaluate the client’s ability to perform ADLs. Which of the following findings indicates standard gait?
   1. The client’s shoulders are rounded slightly forward
   2. The client’s dominant foot bear more weight
   3. The client looks at the floor when walking
   4. The client’s heels touch the ground before their toes
3. A nurse is assessing a client who is on bed rest and notes one calf is 2.5 cm (1 in) larger in diameter than the other calf. Which of the following actions should the nurse take?
   1. Massage the larger calf
   2. Restrict the client’s fluid intake
   3. Place the client’s legs in a depend position
   4. Apply a warm, moist soak to the larger calf
4. A nurse is preparing to assist with the lumber puncture of an infant. The nurse should plan to place the infant in which position?
   1. Semi-Fowler's
   2. Flexed side-laying
   3. prone
   4. trendelenburg

Answer 1

Ans 1. For thinning the mucous secretions and decrease the cough and mucus secretions. So that it can easily spill out . It is the process of removal of excess secretions produced in the mouth and pleural area. It is done under the prescripitions of the physician and under standard pressure and time according to patient condition.

Ans 2. The client’s heels touch the ground before their toes.

Gait, the process of walking and balance, are intricate movements.

The most common symptoms of gait and balance problems include:

• difficulty walking
• trouble with balance
• unsteadiness

A physical and neurological examination can diagnose gait or balance problems. Your doctor will also ask questions about your symptoms and their severities.

Performance testing can then be used to assess individual gait difficulties. Further potential tests to identify causes include:

• hearing tests
• inner ear tests
• vision tests, including watching eye movement

An MRI or CT scan can check your brain and spinal cord. Your doctor will look to find which part of the nervous system is contributing to your gait and balance problems.

A nerve conduction study and electromyogram can be used to evaluate for muscle problems and peripheral neuropathy. You doctor may also order blood tests to evaluate for causes of balance problems.

Ans3. Apply a warm, moist soak to the larger calf and then massage it.

There are two muscles that make up the calf; the gastrocnemius and the soleus. Both muscles are located at the back of the leg, with the gastrocnemius on top and the soleus on bottom. Through multiple means, the gastrocnemius can become enlarged and makes the entire leg look hard and interrupts the smooth line of the leg. For this reason, many people look to calf reduction methods to get this smooth line back.

The effectiveness of massaging your calves is sworn by many women. The technique requires soaking your legs in warm water or in hot towels for 10-15 minutes, then massaging with force in an up and down direction to be able to see results. There are many programs in gyms across the world that boast 10 sessions of massage and exercise in order to slim calves.

Ans 4. Flexed side laying position.

Position the infant in the lateral position with trunk well flexed by the assistant holding the shoulders and legs forward but with the neck extended and legs at a 90 degree angle to the hips - at the edge of the cot. Ensure infant's back is parallel to the cot, with hips and shoulders vertical to the cot (not rotated).

Some degree of flexion of the spine is helpful since it opens up the interspinous spaces and also stretches the skin over the processes, allowing better definition of landmarks.