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How should a healthcare provider care for a patient with a tracheostomy?
- A. Clean the tracheostomy site daily
- B. Change the tracheostomy ties daily
- C. Suction the tracheostomy regularly
- D. Provide humidified oxygen
Correct Answer: C
Rationale: Suctioning the tracheostomy regularly is crucial in caring for a patient with a tracheostomy as it helps keep the airway clear of secretions, preventing blockages and potential complications. Cleaning the tracheostomy site daily is important for hygiene but not as critical as regular suctioning. Changing the tracheostomy ties daily may not be necessary unless soiled or loose. Providing humidified oxygen may be part of the care plan but is not as directly related to maintaining the tracheostomy patency as suctioning.
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What is the most important nursing action when a patient experiences a fall?
- A. Assess the patient for injuries
- B. Call for help
- C. Document the fall
- D. Notify the healthcare provider
Correct Answer: A
Rationale: The most important nursing action when a patient experiences a fall is to assess the patient for injuries. This is critical to identify any potential harm or underlying issues that may require immediate attention. Calling for help and notifying the healthcare provider are important steps, but assessing the patient's condition takes precedence to ensure prompt and appropriate care. Documenting the fall is also necessary but should follow the initial assessment and care provided to the patient.
A healthcare professional is reviewing the laboratory results of a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the professional report to the provider?
- A. Blood glucose level of 130 mg/dL
- B. Serum sodium level of 140 mEq/L
- C. Serum potassium level of 3.2 mEq/L
- D. Platelet count of 250,000/mm³
Correct Answer: C
Rationale: A serum potassium level of 3.2 mEq/L indicates hypokalemia, a complication that should be reported in clients receiving TPN. Hypokalemia can lead to serious cardiac and neuromuscular complications. The other options are within normal ranges and do not indicate immediate concerns for a client receiving TPN. A blood glucose level of 130 mg/dL, serum sodium level of 140 mEq/L, and platelet count of 250,000/mm³ are all considered normal values and do not require immediate intervention.
A nurse is providing discharge teaching to a client who has a new diagnosis of diabetes mellitus. Which of the following client statements indicates a need for further teaching?
- A. I will check my blood glucose level once a week.
- B. I will eat a snack if my blood glucose level is above 200 mg/dL.
- C. I will take my insulin as prescribed, even when I am feeling well.
- D. I will avoid physical activity if my blood glucose level is below 100 mg/dL.
Correct Answer: B
Rationale: The correct answer is B. Clients should eat a snack when their blood glucose level is low, typically below 70-100 mg/dL, not when it is high. Eating a snack when the blood glucose level is above 200 mg/dL can exacerbate hyperglycemia. Choice A is correct as checking blood glucose levels regularly is important in managing diabetes. Choice C is also correct as adherence to prescribed insulin therapy is crucial. Choice D is incorrect as physical activity can help lower blood glucose levels, especially when they are above the target range.
A nurse is observing bonding between a client and her newborn. Which of the following actions by the client requires the nurse to intervene?
- A. Holding the newborn in an en face position
- B. Asking the father to change the newborn's diaper
- C. Requesting the nurse to take the newborn to the nursery so she can rest
- D. Viewing the newborn's actions as uncooperative
Correct Answer: D
Rationale: The correct answer is D because viewing the newborn's actions as uncooperative indicates a lack of bonding, which requires intervention. Choices A, B, and C all involve appropriate and caring actions by the client towards the newborn. Holding the newborn in an en face position promotes bonding, involving the father in caring for the newborn is beneficial for family involvement, and requesting rest by asking the nurse to take the newborn to the nursery is a responsible action to ensure both the client and the newborn get adequate rest.
A client with heart failure is being assessed by a nurse. Which of the following findings indicates the client is experiencing fluid overload?
- A. Dry, hacking cough
- B. Bounding peripheral pulses
- C. Decreased urinary output
- D. Weight loss of 1 kg in 24 hours
Correct Answer: C
Rationale: In clients with heart failure, decreased urinary output is a classic sign of fluid overload. The kidneys try to compensate for the increased volume by reducing urine output, leading to fluid retention. A dry, hacking cough (choice A) is more indicative of heart failure complications like pulmonary edema. Bounding peripheral pulses (choice B) are a sign of increased volume, but not specifically fluid overload. Weight loss of 1 kg in 24 hours (choice D) is not indicative of fluid overload but rather rapid fluid loss.