Nokea
The nurse is reviewing discharge teaching with the parent of a pediatric client who has a new tracheostomy. Which of the following statements by the parent would indicate a correct understanding of the teaching?
- A. I will immediately change the tracheostomy tube if my child has difficulty breathing
- B. I will provide deep suctioning frequently to prevent any airway obstruction.
- C. I will remove the humidifier if my child develops more secretions.
- D. I will travel with two tracheostomy tubes, one of the same size and one a size smaller.
Correct Answer: D
Rationale: Carrying two tracheostomy tubes (same and smaller size) is correct for emergency preparedness. Immediate tube changes, frequent deep suctioning, or removing humidifiers can worsen the situation or are unsafe.
You may also like to solve these questions
A client is seen in the clinic and determined to have a hydatidiform mole. Which diagnostic test can confirm the diagnosis of a hydatidiform mole?
- A. An ultrasound
- B. Alpha-fetoprotein
- C. Human chorionic gonadotrophin
- D. Lecithin sphingomyelin ratio
Correct Answer: A
Rationale: Ultrasound is the primary diagnostic tool for confirming a hydatidiform mole, showing a characteristic 'snowstorm' pattern. Elevated human chorionic gonadotropin supports the diagnosis but is not confirmatory alone.
A client expresses concern about facial appearance after surgery for excision of a melanoma on the side of the nose. What is the best response by the nurse?
- A. Have you shared your concerns with your health care provider (HCP)?
- B. If I were you, I would be more worried about whether the melanoma has spread.
- C. Scar tissue formation is part of the natural healing process. We will teach you how to care for your wound to minimize any complications.
- D. There is special make-up you can use to hide any facial scars left from the surgery.
Correct Answer: C
Rationale: This response addresses the client's concern about appearance by providing education on wound care to minimize scarring, promoting empowerment and trust. A deflects the concern without addressing it. B dismisses the client's feelings and focuses on an unrelated issue. D assumes scarring and offers a cosmetic solution prematurely, which may not address the client's emotional needs.
An elderly client with depression, diabetes mellitus, and heart failure has received a new digoxin prescription for daily use. Which client assessment indicates that the nurse should follow up on serum digoxin levels frequently?
- A. Apical heart rate is 62/min
- B. Blood sugar level is 240 mg/dL (13.3 mmol/L)
- C. Client is taking 20 mg fluoxetine daily
- D. Serum creatinine is 2.3 mg/dL (203 µmol/L)
Correct Answer: D
Rationale: Elevated serum creatinine (2.3 mg/dL) indicates renal impairment, which can lead to digoxin accumulation, necessitating frequent monitoring.
A nurse in the gynecology clinic is reviewing client histories. Which report would be most concerning to the nurse?
- A. 25-year-old client who reports a fish-like vaginal odor for the past month
- B. 30-year-old client with an intrauterine device who reports heavy bleeding with menses
- C. 40-year-old client with endometriosis who reports persistent pain during intercourse
- D. 60-year-old client who reports bloating and pelvic pressure for the past 2 months
Correct Answer: D
Rationale: Bloating and pelvic pressure in a 60-year-old client may indicate serious conditions such as ovarian cancer or other pelvic masses, which require urgent evaluation. Fish-like odor suggests bacterial vaginosis, heavy bleeding with an IUD is common, and pain with endometriosis is expected, making these less concerning.
The nurse is assessing a comatose client receiving gastric tube feedings. Which of the following assessments requires an immediate response from the nurse?
- A. Decreased breath sounds in right lower lobe
- B. Aspiration of a residual of 100 cc of formula
- C. Decrease in bowel sounds
- D. Urine output of 250 cc in past 8 hours
Correct Answer: A
Rationale: Decreased breath sounds in right lower lobe. The most common problem associated with enteral feedings is atelectasis. Maintain client at 30 degrees of head elevation during feedings and monitor for signs of aspiration. Check for tube placement prior to each feeding or every 4 to 8 hours if the client is receiving continuous feeding.