Nokea
A client with a tracheostomy is being cared for by a nurse. The client's partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client's discharge?
- A. Attending a class on tracheostomy care
- B. Verbally explaining all steps in the procedure
- C. Performing the procedure independently
- D. Asking relevant questions about suctioning
Correct Answer: C
Rationale: The correct answer is C: Performing the procedure independently. This indicates readiness for discharge as it demonstrates the partner's ability to safely and effectively perform suctioning without direct supervision. Attending a class (A) and asking relevant questions (D) are important but do not necessarily indicate competence in performing the procedure. Verbally explaining the steps (B) shows understanding but does not confirm practical skill.
You may also like to solve these questions
Which category of complementary and alternative medicine involves healing theory and practice that evolved from other cultures?
- A. Energy medicine
- B. Whole medical systems
- C. Manipulative and body-based therapies
- D. Biologically based practices
Correct Answer: B
Rationale: Whole medical systems, such as Ayurveda and Traditional Chinese Medicine, incorporate theories and practices developed in other cultures.
While caring for a client with extensive partial and full-thickness burns of the head, neck, and chest, which risk should the nurse prioritize for assessment and intervention?
- A. Airway obstruction
- B. Infection
- C. Fluid imbalance
- D. Paralytic ileus
Correct Answer: A
Rationale: The correct answer is A: Airway obstruction. This should be prioritized because burns to the head, neck, and chest can lead to swelling and inflammation, potentially compromising the airway. Maintaining a clear airway is crucial for oxygenation and ventilation. If the airway becomes obstructed, it can quickly lead to respiratory distress or failure. Assessing for signs of airway compromise and intervening promptly is essential to prevent serious complications.
Choices B, C, and D are incorrect because while infection, fluid imbalance, and paralytic ileus are also important considerations in burn care, they are not as immediately life-threatening as airway obstruction in this case. Infection can be managed with appropriate wound care, fluid imbalance can be addressed with fluid resuscitation, and paralytic ileus can be treated with medications and bowel management strategies.
While caring for an unconscious patient, the nurse discovers a stage 2 pressure ulcer on the patient’s heel. During care of the ulcer, what is the nurse’s understanding of the patient’s perception of pain?
- A. The patient will have a behavioral response if pain is perceived.
- B. The area should be treated as a painful lesion, using gentle cleansing and dressing.
- C. The area can be thoroughly scrubbed because the patient is not able to perceive pain.
- D. All nociceptive stimuli that are transmitted to the brain result in the perception of pain.
Correct Answer: B
Rationale: The correct answer is B. Even in unconscious patients, the area should be treated gently to avoid exacerbating potential pain.
To prevent agitation during the patient's recovery from anesthesia, when should the nurse begin orientation explanations?
- A. When the patient is awake
- B. When the patient first arrives in the PACU
- C. When the patient becomes agitated or frightened
- D. When the patient can be aroused and recognizes where he or she is
Correct Answer: B
Rationale: Early orientation helps prevent confusion and agitation as the patient recovers from anesthesia.
The main goal of treatment for acute glomerulonephritis is to
- A. encourage activity.
- B. encourage high protein intake.
- C. maintain fluid balance.
- D. teach intermittent urinary catheterization.
Correct Answer: C
Rationale: Maintaining fluid balance is critical in managing acute glomerulonephritis due to potential fluid overload.