Nokea
The healthcare provider is providing care to a client with a tracheostomy. Which action should the healthcare provider take to prevent tracheostomy complications?
- A. Use sterile technique when performing tracheostomy care.
- B. Suction the tracheostomy tube every hour.
- C. Keep the tracheostomy tube cuff inflated at all times.
- D. Change the tracheostomy ties daily.
Correct Answer: A
Rationale: The correct answer is A: Use sterile technique when performing tracheostomy care. This is crucial to prevent infections that can lead to complications. Sterile technique helps minimize the risk of introducing harmful pathogens into the tracheostomy site. Using clean rather than sterile technique can increase the client's risk of infection.
Choice B is incorrect because suctioning the tracheostomy tube every hour can lead to mucosal damage and increase the risk of infection. Choice C is incorrect because keeping the tracheostomy tube cuff inflated at all times can cause pressure ulcers and damage the trachea. Choice D is incorrect because changing the tracheostomy ties daily is unnecessary and can increase the risk of dislodging the tracheostomy tube, leading to complications.
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A client with a newly created ileostomy has not had ostomy output for the past 12 hours and reports worsening nausea. What is the nurse's priority action?
- A. Facilitate a referral to the wound-ostomy-continence (WOC) nurse
- B. Report signs and symptoms of obstruction to the health care provider
- C. Encourage the client to mobilize to enhance mobility
- D. Contact the health care provider to obtain a swab of the stoma for culture
Correct Answer: B
Rationale: The correct answer is B: Report signs and symptoms of obstruction to the health care provider. The priority action in this scenario is to address the possibility of an obstruction, which could be a life-threatening complication. Reporting to the healthcare provider allows for prompt assessment and intervention to prevent further complications. A: Referring to the WOC nurse may be necessary but is not the priority when obstruction is suspected. C: Encouraging mobilization is important for overall health but not the priority in this urgent situation. D: Obtaining a swab for culture is not the priority when obstruction is suspected.
A client with hepatic encephalopathy is being treated with lactulose. What is an expected outcome of this treatment?
- A. Reduction in blood ammonia levels
- B. Improvement in liver enzyme levels
- C. Decrease in bilirubin levels
- D. Increase in urine output
Correct Answer: A
Rationale: Step-by-step rationale:
1. Lactulose works by reducing blood ammonia levels through promoting its excretion in the stool.
2. Hepatic encephalopathy is caused by elevated blood ammonia levels affecting brain function.
3. Therefore, the expected outcome of lactulose treatment is a reduction in blood ammonia levels, improving the client's condition.
Summary:
- Reduction in blood ammonia levels is the correct outcome as lactulose targets this mechanism.
- Improvement in liver enzyme levels and decrease in bilirubin levels are not direct effects of lactulose.
- Increase in urine output is not a typical outcome of lactulose treatment for hepatic encephalopathy.
What health promotion teaching should prioritize to prevent drug-induced hepatitis?
- A. Finish all prescribed courses of antibiotics, regardless of symptom resolution
- B. Adhere to dosing recommendations of over-the-counter analgesics
- C. Ensure that expired medications are disposed of safely
- D. Ensure that pharmacists regularly review drug regimens for potential interactions
Correct Answer: B
Rationale: The correct answer is B because adhering to dosing recommendations of over-the-counter analgesics can help prevent drug-induced hepatitis by avoiding potential liver damage from excessive doses. Over-the-counter analgesics like acetaminophen can be hepatotoxic if taken in high amounts. Finishing all prescribed courses of antibiotics (A) is important for antibiotic resistance but does not specifically prevent drug-induced hepatitis. Ensuring safe disposal of expired medications (C) is crucial for environmental safety but does not directly prevent drug-induced hepatitis. Having pharmacists review drug regimens for potential interactions (D) is important for overall medication safety but does not specifically address the prevention of drug-induced hepatitis.
A client's health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohn disease, rather than ulcerative colitis, as the cause of the client's signs and symptoms?
- A. A pattern of distinct exacerbations and remissions
- B. Severe diarrhea
- C. An absence of blood in stool
- D. Involvement of the rectal mucosa
Correct Answer: C
Rationale: The correct answer is C: An absence of blood in stool. This suggests Crohn's disease over ulcerative colitis because Crohn's can involve any part of the GI tract and may not always present with blood in stool, in contrast to ulcerative colitis which typically involves the rectum and almost always presents with blood in stool due to continuous inflammation in the colon. Choices A, B, and D are more commonly associated with ulcerative colitis, which typically presents with a pattern of exacerbations and remissions, severe diarrhea, and rectal mucosal involvement.
A client with a history of atrial fibrillation is prescribed dabigatran (Pradaxa). Which instruction should the nurse include in the client's teaching?
- A. Take the medication with food to improve absorption.
- B. Avoid foods high in vitamin K.
- C. Take the medication at the same time each day.
- D. Increase your intake of high-potassium foods.
Correct Answer: C
Rationale: The correct answer is C: Take the medication at the same time each day. This instruction is crucial for maintaining consistent blood levels of dabigatran, maximizing its effectiveness in preventing blood clots. Taking it at the same time each day helps establish a routine and reduces the risk of missed doses.
Choice A is incorrect because dabigatran should be taken without regard to meals. Choice B is incorrect as vitamin K does not interact with dabigatran. Choice D is incorrect because increasing high-potassium foods is not necessary for dabigatran therapy.