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A nurse is caring for a client with a tracheostomy. 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. Performing the procedure independently
- B. Preparing the suction equipment but needing assistance
- C. Demonstrating knowledge of the tracheostomy care instructions
- D. Asking for assistance with the suctioning procedure
Correct Answer: A
Rationale: The correct answer is A. Performing the procedure independently indicates readiness for discharge as it shows the partner has mastered the skill and can provide proper care without supervision. Choice B indicates the partner still needs assistance, choice C shows knowledge but not necessarily competency, and choice D suggests continued reliance on the nurse.
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A client is teaching a client who has a new prescription for hydrochlorothiazide for management of hypertension. Which of the following instructions should the nurse include?
- A. Monitor for leg cramps.
- B. Increase sodium intake.
- C. Monitor for headache.
- D. Take the medication at bedtime.
Correct Answer: A
Rationale: Rationale: Correct answer is A. Leg cramps are a common side effect of hydrochlorothiazide due to electrolyte imbalance. Monitoring for leg cramps will help in identifying and managing this side effect promptly. Choices B and D are incorrect as hydrochlorothiazide can lead to electrolyte depletion, so increasing sodium intake is not recommended, and taking the medication at bedtime may increase nighttime urination. Choice C is incorrect as headaches are not a common side effect of hydrochlorothiazide.
A nurse works with an AP assigned to bathe a client with herpes zoster. The AP asks if it is contagious. What should the nurse say?
- A. Herpes zoster is not contagious to people who have had chickenpox.
- B. Herpes zoster spreads through the air.
- C. Herpes zoster is highly contagious to everyone.
- D. Herpes zoster only spreads through blood contact.
Correct Answer: A
Rationale: The correct answer is A. Herpes zoster, also known as shingles, is caused by the reactivation of the varicella-zoster virus, which also causes chickenpox. Individuals who have had chickenpox in the past are not at risk of getting shingles from someone with herpes zoster. The virus is not transmitted through the air (choice B) or through blood contact only (choice D). It is not highly contagious to everyone (choice C). By explaining to the AP that herpes zoster is not contagious to individuals who have had chickenpox, the nurse provides accurate information and helps alleviate concerns about the spread of the virus.
A nurse assesses a client in skeletal traction. What indicates infection at the pin sites?
- A. Pallor
- B. Fever
- C. Bradycardia
- D. Elevated blood pressure
Correct Answer: B
Rationale: The correct answer is B: Fever. Infection at the pin sites in skeletal traction commonly presents with systemic signs like fever. Fever is a typical response to infection as the body tries to fight off the invading pathogens. Pallor, bradycardia, and elevated blood pressure are not specific indicators of infection at pin sites. Pallor may indicate poor perfusion, bradycardia is a slow heart rate which is not typically associated with infection, and elevated blood pressure can be a response to various stressors but not a specific sign of infection at pin sites. In summary, fever is the most reliable indicator of infection at pin sites due to its systemic nature.
A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?
- A. Skin grafting will be done to replace damaged tissue.
- B. Large incisions will be made in the eschar to improve circulation.
- C. This is a procedure to remove dead tissue from the burn area.
- D. Escharotomy is the removal of the burned area and will not improve circulation.
Correct Answer: B
Rationale: The correct answer is B: Large incisions will be made in the eschar to improve circulation. Escharotomy involves making incisions through the eschar (dead tissue) to relieve constriction and improve circulation in the burned area. By performing escharotomy, blood flow is restored, reducing the risk of compartment syndrome and tissue necrosis.
Choice A is incorrect because skin grafting is a separate procedure done to replace damaged tissue, not part of an escharotomy. Choice C is incorrect as it describes debridement, not escharotomy. Choice D is incorrect since escharotomy aims to improve circulation rather than remove the burned area entirely.
A nurse is monitoring a client who has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should the nurse take?
- A. Reposition the client
- B. Check the chest tube for kinks
- C. Increase the suction pressure
- D. Administer pain medication
Correct Answer: A
Rationale: Repositioning the client can help alleviate chest burning caused by the chest tube.