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What are the key nursing interventions for a patient with a tracheostomy?
- A. Maintain a patent airway and monitor for infection
- B. Suction airway secretions and provide humidified oxygen
- C. Educate patient on self-care and tracheostomy cleaning
- D. Change tracheostomy ties daily
Correct Answer: A
Rationale: The correct answer is to maintain a patent airway and monitor for infection. These are crucial nursing interventions for patients with tracheostomies to ensure adequate oxygenation and prevent complications. Suctioning airway secretions and providing humidified oxygen can be part of the care plan but are not as essential as maintaining a patent airway. Educating the patient on self-care and tracheostomy cleaning is important for long-term management but is not as immediate as ensuring a patent airway and monitoring for infection. Changing tracheostomy ties daily is a specific task related to tracheostomy care but is not as critical as ensuring the airway is clear and infection-free.
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How should a healthcare provider educate a patient with hypertension about lifestyle modifications?
- A. Reduce sodium intake
- B. Increase physical activity
- C. Quit smoking
- D. Avoid alcohol
Correct Answer: A
Rationale: When educating a patient with hypertension about lifestyle modifications, reducing sodium intake is crucial as excess sodium can contribute to high blood pressure. While increasing physical activity is beneficial for overall health, it is not the primary lifestyle modification specifically targeted at hypertension. Quitting smoking and avoiding alcohol are important for general health but are not the first-line lifestyle modifications recommended for hypertension. Therefore, the correct answer is to reduce sodium intake.
What are common risk factors for urinary tract infections (UTIs)?
- A. Poor hygiene and dehydration
- B. Increased sexual activity and pregnancy
- C. Use of urinary catheters and prolonged bed rest
- D. Family history and obesity
Correct Answer: A
Rationale: The correct answer is A: Poor hygiene and dehydration are common risk factors for urinary tract infections (UTIs). While choices B, C, and D may play a role in certain cases, poor hygiene and dehydration are more universally recognized as key factors contributing to UTIs. Increased sexual activity and pregnancy (choice B) can also increase the risk of UTIs, but they are not as universal as poor hygiene and dehydration. Choices C and D, the use of urinary catheters and prolonged bed rest, and family history and obesity, respectively, are risk factors for UTIs but are not as commonly associated as poor hygiene and dehydration.
A nurse is teaching a client who has gastroesophageal reflux disease (GERD) about ways to reduce symptoms. Which of the following instructions should the nurse include?
- A. Avoid lying down after meals
- B. Eat large meals to reduce acid production
- C. Drink carbonated beverages with meals
- D. Consume spicy foods to improve digestion
Correct Answer: A
Rationale: The correct answer is A: 'Avoid lying down after meals.' This instruction is important for clients with GERD as it helps reduce reflux symptoms. Lying down after meals can worsen GERD symptoms by allowing stomach acid to flow back into the esophagus. Choice B is incorrect because eating large meals can actually increase acid production and exacerbate GERD symptoms. Choice C is incorrect as carbonated beverages can trigger acid reflux in individuals with GERD. Choice D is also incorrect because consuming spicy foods can irritate the esophagus and lead to increased reflux symptoms.
A nurse is caring for a client with a chest tube post-surgery. What is the most important assessment?
- A. Ensure the chest tube is clamped periodically
- B. Check for air leaks and ensure proper chest tube function
- C. Encourage deep breathing and coughing every 2 hours
- D. Ensure the client is positioned in a high Fowler's position
Correct Answer: B
Rationale: The correct answer is B: 'Check for air leaks and ensure proper chest tube function.' This is the most important assessment for a client with a chest tube post-surgery because it ensures that the chest tube is functioning properly. Checking for air leaks helps prevent complications such as pneumothorax or hemothorax. Choice A is incorrect because clamping the chest tube periodically can lead to serious complications and should not be done unless specifically ordered by a healthcare provider. Choice C is important for promoting lung expansion but is not the most critical assessment related to the chest tube. Choice D is also important for respiratory function but is not the priority when assessing a chest tube post-surgery.
A nurse is reviewing the medical record of a client who has diabetes mellitus and is receiving insulin. Which of the following findings should the nurse report to the provider?
- A. Hemoglobin A1c of 6%
- B. Fasting blood glucose of 90 mg/dL
- C. Blood glucose of 200 mg/dL
- D. Blood glucose of 100 mg/dL
Correct Answer: C
Rationale: A blood glucose level of 200 mg/dL indicates hyperglycemia and should be reported for potential insulin adjustment.