Nokea
A client is being taught how to care for their tracheostomy at home. Which of the following instructions should the nurse include in the teaching?
- A. Use tracheostomy covers when outdoors.
- B. Clean the tracheostomy site with hydrogen peroxide daily.
- C. Change the tracheostomy tube weekly.
- D. Apply ointment around the tracheostomy site.
Correct Answer: A
Rationale: The correct instruction is to use tracheostomy covers when outdoors. Tracheostomy covers serve to protect the airway from environmental contaminants, reducing the risk of infection. Choice B is incorrect because hydrogen peroxide can be irritating to the skin and is not recommended for cleaning the tracheostomy site. Choice C is incorrect as tracheostomy tubes should not be routinely changed weekly unless there is a specific medical indication. Changing it without a need can introduce infection or damage the stoma. Choice D is incorrect as applying ointment around the tracheostomy site can lead to occlusion of the stoma and interfere with breathing.
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The nurse is preparing to administer a subcutaneous injection of enoxaparin (Lovenox). Which site is most appropriate for the LPN/LVN to use?
- A. Deltoid muscle
- B. Ventrogluteal site
- C. Abdomen
- D. Dorsogluteal site
Correct Answer: C
Rationale: The abdomen is the most appropriate site for administering subcutaneous injections of enoxaparin (Lovenox). Enoxaparin is typically administered in the abdomen due to better absorption and reduced risk of injury to underlying structures. The deltoid muscle is not recommended for subcutaneous injections of enoxaparin due to the potential risk of injury to underlying structures. The ventrogluteal and dorsogluteal sites are more appropriate for intramuscular injections rather than subcutaneous injections.
A client needs to maintain a positive nitrogen balance for wound healing. Which of the following food items should the nurse recommend as a good source of complete protein?
- A. Cheddar cheese
- B. White rice
- C. Apples
- D. Green beans
Correct Answer: A
Rationale: Cheddar cheese is the correct answer as it is a good source of complete protein that contains all essential amino acids required for maintaining a positive nitrogen balance for wound healing. Complete proteins provide all essential amino acids needed by the body. White rice, apples, and green beans do not offer complete proteins like cheddar cheese, making them inadequate choices for this purpose.
A nurse is collecting a blood pressure reading from a client who is sitting in a chair. The nurse determines that the client's BP is 158/96 mmHg. Which of the following actions should the nurse take?
- A. Ensure that the width of the BP cuff is appropriate for the client's arm circumference.
- B. Reposition the client supine and recheck their BP.
- C. Recheck the client's BP and measure their other arm for comparison.
- D. Request that another nurse check the client's BP in 30 minutes.
Correct Answer: C
Rationale: When a nurse obtains a blood pressure reading that is elevated, the appropriate action is to recheck the client's BP and measure the other arm for comparison. This step helps ensure accuracy by ruling out errors like improper cuff size, positioning, or equipment malfunction. Repositioning the client supine is not necessary unless the client shows signs of distress or symptoms. Ensuring the appropriate cuff width is important for accurate readings but does not address the immediate need to confirm the current BP. Requesting another nurse to check the BP in 30 minutes delays immediate action and does not address the need for verification and comparison of the current reading.
A client with a history of peptic ulcer disease is admitted with abdominal pain. Which finding should the LPN/LVN report to the healthcare provider immediately?
- A. Positive bowel sounds
- B. Rebound tenderness
- C. Increased appetite
- D. Elevated temperature
Correct Answer: D
Rationale: Elevated temperature is the correct finding to report immediately in a client with a history of peptic ulcer disease and abdominal pain. This could indicate a perforation or worsening of the condition, requiring prompt medical attention. Positive bowel sounds (Choice A) are a normal finding and not a cause for concern. Rebound tenderness (Choice B) is concerning but does not require immediate attention compared to an elevated temperature. Increased appetite (Choice C) is not a red flag symptom for peptic ulcer disease and can be considered a positive sign, not requiring immediate attention.
A client asks about the purpose of advance directives. Which of the following statements should the nurse make?
- A. They allow the court to overrule an adult client's refusal of medical treatment.
- B. They indicate the form of treatment a client is willing to accept in the event of a serious illness.
- C. They permit a client to withhold medical information from health care personnel.
- D. They allow health care personnel in the emergency department to stabilize a client's condition.
Correct Answer: B
Rationale: The correct answer is B. Advance directives specify the type of medical treatment a client wishes to receive or avoid in the event of a serious illness. Choice A is incorrect because advance directives do not allow the court to overrule a client's refusal of medical treatment; they empower the client to make their own healthcare decisions. Choice C is incorrect because advance directives do not permit a client to withhold medical information; they provide guidance on the client's treatment preferences. Choice D is incorrect because advance directives do not specifically address the actions of health care personnel in the emergency department; they focus on the client's treatment preferences in general.