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A nurse is performing tracheostomy care for a patient and plans to remove copious secretions. What actions should the nurse take? What action should the nurse take for tracheostomy suctioning?
- A. Lubricate the suction catheter tip with sterile saline
- B. Hyperventilate the patient on 100% oxygen prior to suctioning
- C. Perform chest physiotherapy prior to suctioning
- D. Suction two to three times with a 60-second pause between passes
Correct Answer: D
Rationale: The correct answer is D: Suction two to three times with a 60-second pause between passes. This is the correct action for tracheostomy suctioning to prevent hypoxia and tissue damage. Suctioning should be limited to 10-15 seconds to minimize the risk of hypoxia. Pausing between passes allows the patient to recover oxygen saturation levels. Choice A is incorrect because lubricating the suction catheter tip with sterile saline is not necessary for tracheostomy suctioning. Choice B is incorrect as hyperventilating the patient on 100% oxygen prior to suctioning can lead to respiratory alkalosis. Choice C is incorrect as performing chest physiotherapy prior to suctioning is not indicated in tracheostomy care.
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A nurse is caring for a preschooler. Which of the following findings should the nurse report to the healthcare provider immediately? Which finding in a preschooler should the nurse report immediately?
- A. Platelet count.
- B. Emesis.
- C. Absolute neutrophil count.
- D. Loss of appetite.
Correct Answer: C
Rationale: The correct answer is C: Absolute neutrophil count. Neutrophils are key components of the immune system, and a low absolute neutrophil count can indicate an increased risk of infection. In preschoolers, any significant deviation from the normal range should be reported promptly to the healthcare provider to prevent serious complications. Platelet count (A) may indicate bleeding disorders but is not as urgent as a low neutrophil count. Emesis (B) and loss of appetite (D) are common in preschoolers and may not be immediate concerns unless persistent or severe. Reporting a low absolute neutrophil count is crucial for timely intervention and management.
A nurse is caring for a patient hospitalized for the treatment of severe depression. Which of the following nursing approaches should be included in the patient's care plan? Which approach should be included for severe depression?
- A. Spend time sitting with the patient.
- B. Offer the patient choices of activities.
- C. Establish a patient relationship.
- D. Explore the truth of the patient's statements.
Correct Answer: A
Rationale: The correct answer is A: Spend time sitting with the patient. Spending time with the patient demonstrates empathy, support, and a willingness to listen, which are crucial for patients with severe depression. It helps build a therapeutic relationship and provides emotional comfort. Choice B focuses more on autonomy and may not address the patient's emotional needs. Choice C is important but is a broad concept that is encompassed by spending time with the patient. Choice D may come off as confrontational and potentially exacerbate the patient's distress.
A nurse is educating a patient with diabetes who has been prescribed insulin glargine. What information should the nurse provide about this type of insulin?,What information should be provided about insulin glargine?
- A. Insulin glargine lasts for 3 to 6 hours.
- B. Insulin glargine lasts for 18 to 24 hours.
- C. Insulin glargine lasts for 16 to 24 hours.
- D. Insulin glargine lasts for 6 to 10 hours.
Correct Answer: B,C
Rationale: The correct answer is B and C. Insulin glargine is a long-acting insulin that provides a basal level of insulin over an extended period. Option B states that it lasts for 18 to 24 hours, which is accurate as it mimics the body's natural basal insulin secretion. Option C also mentions 16 to 24 hours, which is within the range of the duration of action for insulin glargine. Option A stating 3 to 6 hours is incorrect as it does not reflect the long-acting nature of insulin glargine. Option D stating 6 to 10 hours is also incorrect as it underestimates the duration. It is important for the nurse to emphasize the prolonged action of insulin glargine to ensure proper understanding and management by the patient.
A nurse is caring for a patient who is 9 days postoperative following a total laryngectomy. The nurse removes the patient's NG tube and initiates oral feedings. Which of the following statements should the nurse make? Which statement should the nurse make post-laryngectomy?
- A. You should have no trouble swallowing fluids.
- B. It is no longer possible for you to choke on or aspirate food.
- C. I will add a thickener to your liquids to prevent aspiration.
- D. Tuck your chin when you swallow so you won't choke.
Correct Answer: D
Rationale: The correct answer is D: "Tuck your chin when you swallow so you won't choke." After a laryngectomy, patients have altered anatomy that can affect swallowing. Tucking the chin helps close off the airway during swallowing, reducing the risk of choking. This technique directs the food towards the esophagus instead of the trachea, minimizing the risk of aspiration. Choices A, B, and C are incorrect because they do not address the specific swallowing precautions needed post-laryngectomy. Choice A assumes normal swallowing function, which may not be the case. Choice B is inaccurate as aspiration can still occur post-laryngectomy. Choice C is not specific to the patient's individual needs and may not be necessary.
A nurse is caring for a patient who is postoperative following a thyroidectomy. Which of the following findings should the nurse monitor for? Which finding should the nurse monitor post-thyroidectomy?
- A. Hypotension
- B. Tachycardia
- C. Hyperglycemia
- D. Bradypnea
Correct Answer: B
Rationale: The correct answer is B: Tachycardia. Following a thyroidectomy, the nurse should monitor for tachycardia due to the risk of thyroid storm, which can cause increased heart rate. Hypotension (A) is less common post-thyroidectomy. Hyperglycemia (C) is not a typical finding post-thyroidectomy. Bradypnea (D) is not expected, as respiratory rate should be monitored for signs of airway obstruction.