Nokea
A nurse is providing discharge teaching to the partner of a client who has a tracheostomy. Which of the following information should the nurse include in the teaching?
- A. How to operate the portable suction machine
- B. How to secure the tracheostomy tube with ties at the back of the neck
- C. How to change the nondisposable tracheostomy tube daily
- D. How to change the tracheostomy dressing using clean technique
Correct Answer:
Rationale: Correct Answer: B. How to secure the tracheostomy tube with ties at the back of the neck.
Rationale: Securing the tracheostomy tube with ties is crucial to prevent accidental dislodgement and ensure proper placement for oxygenation. This step helps maintain the airway and prevents complications. Teaching this ensures safety and proper care for the client.
Incorrect Choices:
A: Operating the portable suction machine is important but not the priority for discharge teaching.
C: Changing the nondisposable tracheostomy tube daily is not recommended as it can increase the risk of infection.
D: Changing the tracheostomy dressing using clean technique is essential, but securing the tube takes precedence in discharge teaching.
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A nurse is providing discharge teaching about home care of a surgical incision to a client who speaks a different language from the nurse. The nurse is communicating with the client using an interpreter. Which of the following actions should the nurse take?
- A. Speak slowly when talking to the interpreter.
- B. Pause in the middle of sentences
- C. Speak directly to the client
- D. Use gestures to convey meaning
Correct Answer: C
Rationale: The correct answer is C: Speak directly to the client. This is important because even when using an interpreter, the nurse should maintain eye contact and address the client directly to establish trust and ensure the message is accurately conveyed. Speaking slowly (choice A) may be helpful, but it is not as crucial as direct communication. Pausing in the middle of sentences (choice B) could lead to confusion. Using gestures (choice D) may not always accurately convey the intended message. Therefore, speaking directly to the client is the most effective way to ensure clear communication and understanding.
To prevent a compromise in placental blood flow during the intraoperative period, which of the following actions should the nurse take?
- A. Position the client in reverse Trendelenburg
- B. Place a wedge under one of the client's hips.
- C. Assist the client into the lithotomy position.
- D. Insert a pillow under the clients frees
Correct Answer: B
Rationale: Hip wedges optimize maternal blood flow.
Which of the following food choices should the nurse include on the client's food tray?
- A. Bacon and cheese quiche with milk
- B. Scrambled eggs and toast with milk
- C. Shrimp salad and tomato soup with milk
- D. Ham sandwich with milk
Correct Answer: B
Rationale: Kosher diets exclude pork and shellfish.
Which of the following actions should the nurse take to evaluate the effectiveness of the procedure?
- A. Examine for leakage at the site of the procedure
- B. Compare the client's current weight with preprocedural weight
- C. Confirm that the client is able to urinate.
- D. Check the client's serum albumin levels.
Correct Answer: B
Rationale: The correct answer is B: Compare the client's current weight with preprocedural weight. This is the most appropriate action to evaluate the effectiveness of the procedure because changes in weight can indicate fluid retention or loss, which are common outcomes of many procedures. This comparison helps assess if the procedure had the desired effect on the client's fluid status.
Examine for leakage at the site of the procedure (A) is not the best action to evaluate the procedure's effectiveness as leakage may not always correlate with the overall success of the procedure. Confirming that the client is able to urinate (C) is important but may not directly indicate the effectiveness of the procedure. Checking the client's serum albumin levels (D) is relevant for assessing nutritional status but may not directly evaluate the procedure's effectiveness.
For each finding. click to specify if the finding is consistent with pancreatitis or peritonitis Each finding may support more than one disease process.
- A. Bloody stools
- B. Hyperbilirubinemia
- C. Abdominal pain
- D. Elevated WBC court
Correct Answer: A,B,C,D
Rationale: The correct answer is .
Rationale:
1. Bloody stools can be seen in both pancreatitis and peritonitis due to gastrointestinal bleeding.
2. Hyperbilirubinemia is a common finding in pancreatitis due to obstruction of the bile duct by edema or inflammation.
3. Abdominal pain is a hallmark symptom of both pancreatitis and peritonitis, indicating inflammation or irritation of the abdominal structures.
4. Elevated WBC count is a sign of infection or inflammation, which can be present in both pancreatitis and peritonitis.
Summary:
- Bloody stools: Supports both pancreatitis and peritonitis.
- Hyperbilirubinemia: Supports pancreatitis.
- Abdominal pain: Supports both pancreatitis and peritonitis.
- Elevated WBC count: Supports both pancreatitis and peritonitis.
Other choices are incorrect because they do not align with the typical clinical presentations of pancreatitis