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A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take each time he provides tracheostomy care? Select all.
- A. Apply the oxygen source loosely if the SPO2 decreases during the procedure
- B. Use surgical asepsis to remove & clean the inner cannula
- C. Clean the outer surfaces in a circular motion from the stoma site outward
- D. Replace the tracheostomy ties with new ties
- E. Cut a slit in gauze squares to place beneath the tube holder
Correct Answer: A, B, C
Rationale: The correct actions are A, B, and C. A) Applying the oxygen source loosely if the SPO2 decreases during the procedure ensures adequate oxygenation. B) Using surgical asepsis to remove and clean the inner cannula prevents infection. C) Cleaning the outer surfaces in a circular motion from the stoma site outward helps prevent contamination. Other options are incorrect because: D) Replacing the tracheostomy ties with new ties is not necessary each time. E) Cutting a slit in gauze squares is not a standard practice for tracheostomy care.
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A nurse is caring for a client who has had diarrhea for the past 4 days. When assessing the client, the nurse should expect which of the following findings? Select all.
- A. Bradycardia
- B. Hypotension
- C. Fever
- D. Poor skin turgor
- E. Peripheral edema
Correct Answer: B, C, D
Rationale: The correct answers are B, C, and D. Diarrhea leads to fluid loss, causing hypotension (B) due to decreased blood volume, fever (C) as a result of dehydration and infection, and poor skin turgor (D) due to decreased tissue hydration. Bradycardia (A) is unlikely as the body compensates for dehydration with increased heart rate. Peripheral edema (E) is not expected as dehydration leads to fluid depletion, not retention.
A nurse is assessing a client who is 5 days postop following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound & blood specimens for culture & sensitivity. Which of the following assessment findings should the nurse expect? Select all.
- A. Increase in incisional pain
- B. Fever & chills
- C. Reddened wound edges
- D. Increase in serosanguineous drainage
- E. Decrease in thirst
Correct Answer: A, B, C
Rationale: The correct assessment findings the nurse should expect in a client suspected of having an incisional wound infection include: A) Increase in incisional pain: Infection can cause localized pain. B) Fever & chills: Systemic signs of infection. C) Reddened wound edges: Classic sign of wound infection. Incorrect choices: D) Increase in serosanguineous drainage: This is more indicative of normal wound healing. E) Decrease in thirst: Unrelated to wound infection. Overall, pain, fever, and redness are key signs of infection that the nurse should look out for.
A nurse is preparing to administer digoxin (Lanoxin) to a client who states, 'I don't want to take that med. I do not want one more pill.' Which of the following responses by the nurse is appropriate in this situation?
- A. Your physician prescribed it for you, so you really should take it.
- B. Well, let's just get it over with quickly then.
- C. Okay, I'll just give you your other meds.
- D. Tell me your concerns with taking this med.
Correct Answer: D
Rationale: Correct Answer: D. Tell me your concerns with taking this med.
Rationale: This response demonstrates therapeutic communication by acknowledging the client's feelings and encourages them to express their concerns. It shows empathy and respect for the client's autonomy in decision-making. By understanding the client's reasons for not wanting to take the medication, the nurse can address any misconceptions, provide education, and potentially find alternative solutions. This approach fosters trust and collaboration between the nurse and the client.
Incorrect choices:
A: This response is dismissive of the client's feelings and does not address the underlying concerns.
B: This response does not address the client's reluctance and may come off as insensitive.
C: This response avoids the issue at hand and does not promote open communication.
A nurse is preparing to perform endotracheal suctioning for a client. Which of the following are appropriate guidelines for the nurse to follow? Select all.
- A. Apply suction while withdrawing the catheter
- B. Perform suctioning on a routine basis, Q2-3 hours
- C. Maintain medical asepsis during suctioning
- D. Use a new catheter for each suctioning attempt
- E. Limit suctioning to 2-3 attempts
Correct Answer: A, D, E
Rationale: Correct Answer: A, D, E
Rationale:
A: Apply suction while withdrawing the catheter - This guideline ensures effective removal of secretions without damaging the airway.
D: Use a new catheter for each suctioning attempt - Reusing catheters can introduce infection and compromise patient safety.
E: Limit suctioning to 2-3 attempts - Excessive suctioning can lead to hypoxia and damage to the airway. Limiting attempts is safer for the patient.
Incorrect Choices:
B: Performing suctioning on a routine basis, Q2-3 hours can be harmful as it may lead to unnecessary trauma to the airway and increased risk of infection.
C: Maintaining medical asepsis during suctioning is a general guideline but not specific to endotracheal suctioning.
A client who will undergo neurosurgery the following week tells the nurse in the surgeon's office that he will prepare his advance directives before he goes to the hospital. Which of the following statements by the client indicates to the nurse that he understands advance directives?
- A. I'd rather have my brother make decisions for me, but I know it has to be my wife.
- B. I know they won't go ahead w/the surgery unless I prepare these forms.
- C. I plan to write that I don't want them to keep me on a breathing machine.
- D. I will get my regular doctor to approve my plan before I hand it in at the hospital.
Correct Answer: C
Rationale: The correct answer is C because it demonstrates understanding of advance directives by stating a specific treatment preference, which is not wanting to be kept on a breathing machine. This indicates the client's awareness of the purpose of advance directives in specifying their healthcare wishes.
Choice A is incorrect because it shows a lack of understanding that the client is the one who should make decisions about their care. Choice B is incorrect as it focuses on the surgery proceeding rather than the purpose of advance directives. Choice D is incorrect as it does not show an understanding of the purpose of advance directives but rather a general approval process.