Nokea
A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching?
- A. Remove the outer cannula carefully during cleaning.
- B. Use tracheostomy covers when outdoors.
- C. Use sterile technique when performing tracheostomy care at home.
- D. Cleanse mist with full-strength hydrogen peroxide.
Correct Answer: C
Rationale: The correct answer is C: Use sterile technique when performing tracheostomy care at home. This is crucial to prevent infections and ensure the client's safety. Sterile technique involves maintaining a clean environment, using sterile gloves, and sterile supplies to reduce the risk of introducing harmful microorganisms. Removing the outer cannula during cleaning (A) can increase the risk of accidental dislodgement and should only be done when necessary by a healthcare professional. Tracheostomy covers (B) are used to provide warmth and moisture, not necessarily for infection control. Cleansing mist with full-strength hydrogen peroxide (D) is too harsh and can damage the skin and mucous membranes.
You may also like to solve these questions
A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care?
- A. Critical pathway
- B. Situation background assessment and recommendation (SBAR)
- C. Transfer report
- D. Medication administration record (MAR)
Correct Answer: B
Rationale: The correct answer is B: Situation background assessment and recommendation (SBAR). SBAR is a structured communication tool used in healthcare to provide a concise and focused way of relaying important information between healthcare team members. It helps ensure continuity of care by including essential details such as the patient's situation, background information, assessment findings, and recommendations for further care. SBAR improves communication efficiency, reduces errors, and enhances patient safety.
Choices A, C, and D are incorrect because:
A: Critical pathway is a care plan outlining evidence-based guidelines for patient care but does not provide the detailed communication needed for continuity of care.
C: Transfer report is focused on the transfer of a patient between units or facilities and may not include all the necessary information for continuity of care during a shift change.
D: Medication administration record (MAR) is a document used to record medication administration and does not encompass the comprehensive patient information needed for effective shift handoff.
A nurse is caring for a client who has a terminal illness, and the client's partner indicates effective coping. The nurse should recognize that which of the following statements is an indication of effective coping?
- A. I am not worried because I will have hope that he will be okay.
- B. I am relying on support from our family during this time.
- C. We can plan our family reunion once he recovers and comes home.
- D. We don't see any reason to start discussing funeral arrangements right now.
Correct Answer: B
Rationale: The correct answer is B: "I am relying on support from our family during this time." This statement indicates effective coping because it acknowledges the importance of seeking and utilizing support from family members, which can help reduce feelings of isolation and provide emotional strength. By relying on family support, the client's partner is demonstrating a healthy coping mechanism that promotes resilience and emotional well-being during a challenging situation.
Choice A is incorrect because relying solely on hope without acknowledging the need for support may not address the partner's emotional needs effectively. Choice C is incorrect as it demonstrates denial of the terminal illness and avoidance of the current reality. Choice D is incorrect as it suggests avoidance of discussing important end-of-life decisions, which can hinder effective coping and planning.
A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?
- A. Place the client in a semi-lying position.
- B. Instill 15 mL of irrigation fluid into the catheter with each flush.
- C. Subtract the amount of irrigant used from the client's urine output.
- D. Perform the irrigation using a 20-mL syringe.
Correct Answer: C
Rationale: The correct answer is C: Subtract the amount of irrigant used from the client's urine output. This is the correct action because when using open irrigation technique, the nurse needs to account for the amount of irrigant introduced into the catheter to accurately assess the client's urine output. By subtracting the amount of irrigant used from the total output, the nurse ensures an accurate measurement of the client's urine output. This is crucial for monitoring the client's renal function and fluid balance.
Choice A is incorrect as the client should ideally be in a supine position during catheter irrigation to prevent spillage. Choice B is incorrect as the amount of irrigation fluid instilled should typically be equal to the amount of urine output, not a fixed amount. Choice D is incorrect as a 60-mL syringe is usually recommended for catheter irrigation to avoid excessive force and pressure on the catheter.
A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
- A. Place a name tag on the body.
- B. Obtain the pronouncement of death from the provider.
- C. Remove tubes and indwelling lines.
- D. Wash the client's body.
- E. Ask the client's family members if they would like to view the body.
Correct Answer: B, E, C, D, A
Rationale: 1. Obtain the pronouncement of death from the provider (B): This is the first step to officially confirm the client's passing.
2. Ask the client's family members if they would like to view the body (E): Providing support to the family is crucial.
3. Remove tubes and indwelling lines (C): This step is necessary to prepare the body for respectful handling.
4. Wash the client's body (D): Maintaining dignity and cleanliness is important.
5. Place a name tag on the body (A): This ensures proper identification for all involved.
In summary, obtaining the pronouncement of death is the priority, followed by addressing the emotional needs of the family, preparing the body, and ensuring proper identification. Removing tubes and washing the body come before placing the name tag.
A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions in their airway. Which of the following actions should the nurse take?
- A. Turn the client every 2 hours.
- B. Administer an anti-cholinergic medication.
- C. Hold oral care.
- D. Increase the room's temperature.
Correct Answer: B
Rationale: The correct answer is B: Administer an anti-cholinergic medication. This is because anti-cholinergic medications can help reduce secretions in the airway, thus improving the client's breathing and reducing the noisy respirations. Turning the client every 2 hours (choice A) may provide comfort but does not address the immediate issue of airway secretions. Holding oral care (choice C) is important for overall comfort but does not directly address the client's breathing difficulty. Increasing the room's temperature (choice D) is unlikely to improve the client's respiratory distress and may even make it worse.