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The nurse has completed tracheostomy care for a client whose tracheostomy tube has a nondisposable inner cannula. Which intervention will the nurse implement immediately before reinserting the inner cannula?
- A. Rinsing it in sterile water
- B. Suctioning the client's airway
- C. Tapping it gently against a sterile basin
- D. Drying it with the provided pipe cleaners
Correct Answer: D
Rationale: After washing and rinsing the inner cannula, the nurse taps it dry to remove large water droplets and then uses pipe cleaners specifically for use with a tracheostomy to dry it; then the nurse inserts the cannula into the tracheostomy and turns it clockwise to lock it into place. The nurse should avoid shaking or tapping the inner cannula to prevent contamination. A wet cannula should not be inserted into a tracheostomy because water is a lung irritant.
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A primary health care provider prescribes 1000 mL of normal saline to infuse at 100 mL/hour. The drop factor is 10 drops/mL. The nurse should set the flow rate at how many drops per minute?
Correct Answer: 17
Rationale: It will take 10 hours for 1000 mL to infuse at 100 mL/hour (1000 mL ÷ 100 mL = 10 hour × 60 min = 600 min). Next, use the intravenous (IV) flow rate formula. Formula: Total volume × Drop factor ÷ Time in minutes. 1000 mL × 10 Drops/mL = 10,000 ÷ 600 min = 16.6, or 17 Drops/minute.
The nurse is reviewing the laboratory results for a client who is receiving torsemide 5 mg orally daily. What value should indicate to the nurse that the client might be experiencing an adverse effect of the medication?
- A. A chloride level of 98 mEq/L (98 mmol/L)
- B. A sodium level of 135 mEq/L (135 mmol/L)
- C. A potassium level of 3.1 mEq/L (3.1 mmol/L)
- D. A blood urea nitrogen (BUN) level of 15 mg/dL (5.4 mmol/L)
Correct Answer: C
Rationale: Torsemide is a loop diuretic. The medication can produce acute, profound water loss; volume and electrolyte depletion; dehydration; decreased blood volume; and circulatory collapse. Option 3 is the only option that indicates electrolyte depletion because the normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). The normal chloride level is 98 to 107 mEq/L (98 to 107 mmol/L). The normal sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). The normal BUN level ranges from 10 to 20 mg/dL (3.6 to 7.1 mmol/L).
The nurse is planning care for a client with a chest tube attached to a Pleur-Evac drainage system. The nurse should include which interventions in the plan? Select all that apply.
- A. Changing the client's position often
- B. Clamping the chest tube intermittently
- C. Maintaining the collection chamber below the client's waist
- D. Adding water to the suction control chamber as it evaporates
- E. Taping the connection between the chest tube and the drainage system
Correct Answer: A,C,D,E
Rationale: Changing the client's position frequently is necessary to promote drainage and ventilation. Maintaining the system below waist level is indicated to prevent fluid from reentering the pleural space. Adding water to the suction control chamber is an appropriate nursing action and is done as needed to maintain the full suction level prescribed. Taping the connection between the chest tube and system is also indicated to prevent accidental disconnection. To prevent a tension pneumothorax, the nurse avoids clamping the chest tube, unless specifically prescribed. In many facilities, clamping of the chest tube is contraindicated by agency policy.
In preparation to administer an intermittent tube feeding, the nurse aspirates 40 mL of undigested formula from the client's nasogastric tube. Which intervention should the nurse implement as a result of this finding?
- A. Discard the aspirate and record as client output.
- B. Mix with new formula to administer the feeding.
- C. Dilute with water and inject into the nasogastric tube.
- D. Reinstill the aspirate through the nasogastric tube via gravity and syringe.
Correct Answer: D
Rationale: After checking residual feeding contents, the nurse reinstills the gastric contents into the stomach by removing the syringe bulb or plunger and pouring the gastric contents via the syringe into the nasogastric tube. Gastric contents should be reinstilled (unless they exceed an amount of 100 mL or as defined by agency policy) to maintain the client's fluid and electrolyte balance. The nurse avoids mixing gastric aspirate with fresh formula to prevent contamination. Because the gastric aspirate is a small volume, it should be reinstilled; however, mixing the formula with water can also disrupt the client's fluid and electrolyte balance unless the client is dehydrated.
The nurse assessing the apical heart rates of several different newborn infants notes that which heart rate is normal for this newborn population?
- A. 90 beats per minute
- B. 140 beats per minute
- C. 180 beats per minute
- D. 190 beats per minute
Correct Answer: B
Rationale: The normal heart rate in a newborn infant is approximately 100 to 160 beats per minute. Options 1, 3, and 4 are incorrect. Option 1 indicates bradycardia, and options 3 and 4 indicate tachycardia (greater than 100 beats per minute).