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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 caring for an adolescent who has hyperthermia. Which of the following actions should the nurse take?
- A. Administer oral acetaminophen.
- B. Cover the adolescent with a thermal blanket
- C. Submerge the adolescent's feet in ice water
- D. Initiate seizure precautions.
Correct Answer: D
Rationale: The correct answer is D: Initiate seizure precautions. Hyperthermia can lead to seizures due to the brain's sensitivity to high temperatures. Seizure precautions involve ensuring a safe environment, padding the bed, and having emergency equipment ready. Administering oral acetaminophen (A) is not the priority in hyperthermia as it may not rapidly reduce the temperature. Covering with a thermal blanket (B) may further increase body temperature. Submerging feet in ice water (C) can cause vasoconstriction and shivering, leading to increased core temperature.
Which of the following findings places the client at risk if he receives alteplase?
- A. Family history of malignant hypertension
- B. Hip arthroplasty 1 week ago
- C. Chronic obstructive pulmonary disease
- D. Acute renal failure 6 months ago
Correct Answer: B
Rationale: Recent surgeries increase bleeding risks with thrombolytics.
The nurse notes that sediment is present in the urine.
- A. Which of the following actions should the nurse take to obtain a sterile urine specimen?
- B. Disconnect the catheter from the collection tubing.
- C. Obtain the specimen from the retention port.
- D. Use the balloon port to obtain the sterile specimen.
- E. Unclamp the collection port below the bag
Correct Answer: B
Rationale: Retention ports allow sterile specimen collection.
Which of the following actions should the nurse take?
- A. Place the client in a side-lying position prior to assessing the fetal heart rate.
- B. Measure the fundal height to determine the placement of the ultrasound stethoscope.
- C. Position the ultrasound stethoscope above the symphysis pubis to assess the fetal heart rate.
- D. Perform Leopold maneuvers prior to auscultating the fetal heart rate.
Correct Answer: C
Rationale: The correct answer is C: Position the ultrasound stethoscope above the symphysis pubis to assess the fetal heart rate. This is the correct action because placing the ultrasound stethoscope above the symphysis pubis allows for optimal detection of the fetal heart rate. This location is where the fetal heart sounds are best heard due to the proximity to the fetal heart. Placing the stethoscope in this location ensures accurate assessment of the fetal heart rate.
Choice A is incorrect because placing the client in a side-lying position is not necessary for assessing the fetal heart rate with an ultrasound stethoscope. Choice B is incorrect because measuring fundal height is not relevant to assessing the fetal heart rate. Choice D is incorrect because Leopold maneuvers are used to determine fetal position and presentation, not to assess the fetal heart rate.
A nurse in an emergency department is caring for a child who reports being sexually abused by a family member. Which of the following actions should the nurse take?
- A. Use leading statements to obtain information from the child
- B. Ensure that multiple nurses are present for the physical examination
- C. Explain to the child what will happen when the abuse is reported
- D. Reassure the child that no one will be told about the abuse
Correct Answer: C
Rationale: Correct Answer: C - Explain to the child what will happen when the abuse is reported.
Rationale: It is crucial for the nurse to inform the child about the reporting process to ensure transparency and build trust. This empowers the child and helps them understand the next steps. It also promotes their involvement in decision-making regarding their well-being. By explaining the process, the nurse can offer emotional support and reassurance to the child. This approach respects the child's autonomy and dignity.
Incorrect Choices:
A: Using leading statements can influence the child's responses and compromise the accuracy of information obtained.
B: Having multiple nurses present may intimidate the child and breach confidentiality.
D: Reassuring the child that no one will be told about the abuse may perpetuate feelings of isolation and hinder the necessary intervention.