Nokea
The nurse teaches a patient how to live with a new tracheostomy. Which of the ff. instructions is appropriate?
- A. “Never suction your tracheostomy; you might damage your trachea.”
- B. “”You should not feel bad about the tracheostomy – you should be feel lucky to be alive.”
- C. “Be sure to protect your tracheostomy from pollutants such as powders, hair and chemicals.”
- D. “Your tracheostomy will be cleaned each time you visit your doctor.”
Correct Answer: C
Rationale: The correct answer is C: “Be sure to protect your tracheostomy from pollutants such as powders, hair, and chemicals.” This instruction is appropriate because keeping the tracheostomy site clean and free from pollutants is crucial in preventing infections and complications. Powders, hair, and chemicals can lead to irritation and blockages, increasing the risk of infection.
Explanation of why other choices are incorrect:
A: “Never suction your tracheostomy; you might damage your trachea.” - This is incorrect because suctioning is a necessary part of tracheostomy care to clear secretions and ensure proper breathing.
B: “You should not feel bad about the tracheostomy – you should feel lucky to be alive.” - This is incorrect as it does not provide practical instructions for tracheostomy care and may not address the patient's emotional concerns adequately.
D: “Your tracheostomy will be cleaned each time you visit your doctor.” - This is
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Why should the nurse closely monitor a client to ensure that the venous access device remains in the vein during a transfusion?
- A. It minimizes the risk of phlebitis
- B. It minimizes the risk of circulatory overload
- C. It minimizes the risk of pulmonary
- D. It minimizes the risk of localized edema embolism
Correct Answer: B
Rationale: The correct answer is B: It minimizes the risk of circulatory overload. When a venous access device dislodges during a transfusion, there is a risk of the infusion going into the surrounding tissues instead of the vein, leading to circulatory overload. This can result in fluid overload and potentially lead to serious complications such as heart failure. Monitoring the device ensures that the medication is delivered safely and effectively into the bloodstream.
Choices A, C, and D are incorrect:
A: Monitoring the device does not directly minimize the risk of phlebitis, which is inflammation of the vein.
C: Monitoring the device does not directly minimize the risk of pulmonary complications, which are not typically associated with a dislodged venous access device.
D: Monitoring the device does not directly minimize the risk of localized edema embolism, which is a blockage caused by a blood clot, air bubble, or other material in a blood vessel.
An adult is to receive an IM injection of Morphine for post op pain. Which of the following is necessary for the nurse to assess prior to giving a narcotic analgesic?
- A. The client’s level of alertness and respiratory rate
- B. The last time the client ate or drank something
- C. The client’s bowel habits and last bowel movement
- D. The client’s history of addictions
Correct Answer: A
Rationale: The correct answer is A. Before administering a narcotic analgesic like Morphine, assessing the client's level of alertness and respiratory rate is crucial to ensure they can tolerate the medication without compromising their breathing. Alertness indicates their ability to handle potential side effects, while respiratory rate is vital to monitor for any signs of respiratory depression.
Choice B (last meal) is not directly related to giving a narcotic analgesic, although it may impact the absorption rate. Choice C (bowel habits) and last bowel movement are not immediately relevant to assessing the client's readiness for a narcotic analgesic. Choice D (history of addictions) is important but not the priority when assessing for immediate safety and efficacy of the medication.
A 16 y.o. girl is diagnosed with genital herpes. She is tearful and as she asks what she can do to prevent complications of the disease. Based on the data provided, which nursing diagnosis is appropriate for her plan of care?
- A. Risk for transmission of infection
- B. Pain
- C. Health-seeking behaviours
- D. Ineffective sexuality pattern
Correct Answer: A
Rationale: The correct answer is A: Risk for transmission of infection. This is appropriate because the girl has genital herpes, which is a sexually transmitted infection (STI) that can be transmitted to others through sexual contact. Therefore, the main concern is preventing the spread of the infection to others. Pain (B) is a symptom of herpes but not the primary concern here. Health-seeking behaviors (C) may be relevant for education and prevention, but not the immediate focus. Ineffective sexuality pattern (D) is not directly related to the risk of transmission of infection in this case.
Which of the ff instructions should a nurse give a client with Hodgkin’s disease who is at risk of impaired skin integrity? Choose all that apply
- A. Trim nails short
- B. Keep the neck in midline
- C. Use mild soap
- D. Support and protect bony prominences
Correct Answer: B
Rationale: Step 1: Keeping the neck in midline helps prevent compression of the lymphatic vessels in the neck, reducing the risk of impaired skin integrity in Hodgkin's disease.
Step 2: This position also helps maintain proper blood flow and lymphatic drainage in the neck area.
Step 3: Trimming nails short, using mild soap, and supporting bony prominences are not directly related to preventing impaired skin integrity in Hodgkin's disease.
Summary: Choice B is correct as it directly addresses the specific risk factor of impaired skin integrity in Hodgkin's disease, while the other choices are not as relevant to this particular concern.
Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient? The nurse determines to remove a wound dressing when the patient reveals the time
- A. of the last dressing change and notices old and new drainage. The nurse administers pain medicine due at 1700 at 1600 because the patient reports
- B. increased pain and the family wants something done. The nurse immediately asks the health care provider for an order of potassium when a
- C. patient reports leg cramps.
- D. The nurse elevates a leg cast when the patient reports decreased mobility.
Correct Answer: A
Rationale: The correct answer is A because it demonstrates data validation in nursing clinical decision-making. In this scenario, the nurse considers the patient's self-reported information (time of last dressing change and observation of old and new drainage) as key data points to validate the need for changing the wound dressing. This aligns with the principles of evidence-based practice and ensures that the decision is based on accurate and relevant information.
Choices B, C, and D are incorrect because they do not involve the systematic validation of data to inform the nursing decision-making process. Choice B relies on family input rather than objective data, Choice C jumps to a treatment decision without confirming the underlying cause, and Choice D does not involve validating the patient's reported symptom before taking action.