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During tracheostomy care, what action should a healthcare professional take?
- A. Use clean technique to remove the inner cannula.
- B. Remove the outer cannula for cleaning.
- C. Soak the inner cannula in normal saline.
- D. Change tracheostomy ties if they are wet.
Correct Answer: D
Rationale: Changing tracheostomy ties if they are wet is essential to prevent infection and maintain skin integrity. Wet ties can harbor bacteria, increasing the risk of skin breakdown and other complications. Regularly changing wet ties promotes cleanliness, reduces the likelihood of complications, and ensures optimal care for the client with a tracheostomy.
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A client has a pressure ulcer. Which of the following findings indicates healing of the ulcer?
- A. Increase in drainage.
- B. Decrease in size.
- C. Presence of foul odor.
- D. Reddened wound edges.
Correct Answer: B
Rationale: When a pressure ulcer is healing, there is a decrease in its size as the tissue repair progresses. This reduction in size is a positive indication of the healing process. An increase in drainage, presence of foul odor, or reddened wound edges are typically signs of infection or lack of improvement. Therefore, the correct answer is a decrease in size.
A healthcare provider is planning care for a client who has a pressure ulcer. Which of the following actions should the healthcare provider take?
- A. Massage the reddened area.
- B. Apply a heating pad to the area.
- C. Elevate the head of the bed to 45 degrees.
- D. Reposition the client every 2 hours.
Correct Answer: D
Rationale: Repositioning the client every 2 hours is crucial in preventing pressure ulcers from worsening. This action helps relieve pressure on specific areas, improving circulation and reducing the risk of tissue damage. Massaging the reddened area can further damage the skin, applying heat can increase the risk of skin breakdown, and elevating the head of the bed to 45 degrees may not directly address the pressure ulcer prevention. Proper positioning is essential to avoid prolonged pressure on the affected areas and promote healing.
Following a total hip arthroplasty, what intervention should the healthcare provider implement for the client?
- A. Place a pillow between the client's legs.
- B. Elevate the head of the bed to 45 degrees.
- C. Position the client on the operative side.
- D. Keep the client's legs adducted.
Correct Answer: A
Rationale: Placing a pillow between the client's legs is crucial post hip arthroplasty surgery to prevent hip dislocation. This intervention helps maintain proper alignment and prevents legs from crossing midline, reducing the risk of hip prosthesis dislocation. Elevating the head of the bed to 45 degrees, positioning the client on the operative side, or keeping the client's legs adducted are not recommended postoperative interventions for a total hip arthroplasty, as they can increase the risk of complications and compromise the surgical site.
When providing teaching to a client with a new prescription for digoxin, which of the following instructions should the nurse include?
- A. Take your pulse before taking the medication.
- B. Take the medication with an antacid.
- C. Double the dose if you miss one.
- D. Take the medication with a high-fiber meal.
Correct Answer: A
Rationale: The correct instruction for a client with a new prescription for digoxin is to take their pulse before taking the medication. Digoxin can lead to bradycardia as a side effect, and monitoring the pulse helps in assessing the heart rate prior to medication administration. This precaution allows for the identification of any significant changes in heart rate that may require medical attention.
A client is experiencing dysphagia. Which of the following actions should the nurse take?
- A. Provide small food pieces.
- B. Offer thickened liquids.
- C. Encourage the client to sit upright after meals.
- D. Place food on the unaffected side of the mouth.
Correct Answer: D
Rationale: When caring for a client with dysphagia, placing food on the unaffected side of the mouth can help them chew and swallow more effectively. This technique can assist in minimizing the risk of aspiration and improve the client's ability to manage food safely. Providing small food pieces, offering thickened liquids, and encouraging the client to sit upright after meals are also important interventions in managing dysphagia, but placing food on the unaffected side of the mouth is a specific technique that directly addresses the swallowing difficulty associated with dysphagia.