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The nurse is performing tracheostomy care for a client who has a tracheostomy tube with a disposable inner cannula. Which of the following actions should the nurse take?
- A. Cleanse the stoma using an alcohol-based cleaning solution.
- B. Discontinue humidification once tracheostomy care is complete.
- C. Suction the tracheostomy tube prior to removing the inner cannula.
- D. Remove the outer cannula of the tracheostomy and rinse with sterile water.
Correct Answer: C
Rationale: Suctioning before removing the inner cannula (C) clears secretions and ensures airway patency. Alcohol-based solutions (A) are irritating, humidification (B) is needed, and removing the outer cannula (D) is unsafe.
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A client diagnosed with hypertension has been prescribed a clonidine patch. Which instructions should the nurse include to reinforce prior teaching? Select all that apply.
- A. Apply patch to the upper arm or chest
- B. Fold used patches in half with sticky sides together before discarding
- C. Remove patch if dizziness occurs when getting up
- D. Rotate sites each time a new patch is applied
- E. Shave hair before applying patch
Correct Answer: A, B, D
Rationale: Applying to upper arm/chest (A), folding patches (B), and rotating sites (D) ensure safe use. Removing for dizziness (C) requires medical consultation, and shaving (E) can irritate skin.
A postoperative client with obesity and diabetes mellitus has an abdominal wound and is at risk for poor wound healing. Which of the following interventions does the nurse anticipate to prevent wound dehiscence? Select all that apply.
- A. Administer docusate sodium orally every day
- B. Assist in applying an abdominal binder
- C. Implement caloric restriction to promote weight loss
- D. Monitor blood glucose to maintain tight control
- E. Reinforce teaching to hug a pillow while coughing
Correct Answer: B, D, E
Rationale: Abdominal binder (B), glucose control (D), and pillow hugging (E) reduce wound stress and promote healing. Docusate (A) prevents constipation but not dehiscence, and caloric restriction (C) is inappropriate post-surgery.
The clinic nurse evaluates a client who was prescribed lithium therapy a month ago for bipolar disorder. Which client statement would cause the most concern?
- A. I've felt the need for an afternoon nap most days this week.'
- B. I've gained 3 lb (1.36 kg) since I began taking this medication.'
- C. I've had the stomach flu for the past couple of days.'
- D. My mouth seems to be drier than usual lately.'
Correct Answer: C
Rationale: Stomach flu (C) can cause dehydration, increasing lithium toxicity risk, requiring immediate concern. Naps (A), weight gain (B), and dry mouth (D) are less urgent side effects.
Parents of a 6 month-old breast fed baby ask the nurse about increasing the baby's diet. Which of the following should be added first?
- A. Cereal
- B. Eggs
- C. Meat
- D. Juice
Correct Answer: A
Rationale: Cereal. Strained cereal is recommended as the first solid food for breastfed infants, per pediatric guidelines.
The nurse is reinforcing teaching about home administration of sublingual nitroglycerin tablets to a client with stable angina. Which client statement indicates the need for further teaching?
- A. I can take 1 tablet every 5 minutes, up to 3 times, for chest pain.'
- B. I should call 911 if my chest pain isn't relieved by nitroglycerin.'
- C. I will call my doctor's office if I start experiencing chest pain at rest.'
- D. I will keep one bottle of nitroglycerin in the house and one in the car.'
Correct Answer: D
Rationale: Keeping nitroglycerin in a car (D) risks exposure to heat, reducing efficacy, requiring further teaching. Other statements (A, B, C) are correct.