Nokea
When teaching a client and their family how to care for the client's tracheostomy at home, which of the following should the nurse include?
- A. Use tracheostomy covers when outdoors
- B. Maintain a sterile technique when performing tracheostomy care
- C. Do not remove the outer cannula for routine cleaning
- D. Clean around the stoma with normal saline solution
Correct Answer: A
Rationale: The correct answer is to use tracheostomy covers when outdoors. This practice helps protect the stoma from foreign particles and temperature changes, reducing the risk of infection. Maintaining a sterile technique when performing tracheostomy care (choice B) is important to prevent infections but is not specific to outdoor care. Removing the outer cannula for routine cleaning (choice C) is not recommended as it may cause trauma or dislodgment of the tracheostomy tube. Cleaning around the stoma with povidone-iodine (choice D) is not advisable as it can be irritating to the skin and may impair the healing process.
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When a nurse instructs a client with hearing loss about cleaning their new hearing aids, which statement indicates that the client understands the instructions?
- A. I use a damp cloth to clean the outside part of my hearing aids.
- B. I clean my hearing aids' ear molds with rubbing alcohol.
- C. I always keep the volume of my hearing aids turned up for better hearing.
- D. I remove the batteries from my hearing aids when not in use at night.
Correct Answer: A
Rationale: The correct answer is A because cleaning the outside part of hearing aids with a damp cloth is an appropriate method. Rubbing alcohol can damage ear molds, so choice B is incorrect. Keeping the volume of hearing aids turned up high may lead to discomfort, making choice C incorrect. Removing batteries when not in use at night is good practice for battery life, but it does not directly relate to understanding cleaning instructions, so choice D is less relevant in this context.
A school-aged child has had a long leg (hip to ankle) synthetic cast applied 4 hours ago. Which statement from the mother indicates that teaching has been inadequate?
- A. I will keep the cast covered the next day to prevent skin burning.
- B. I can apply an ice pack over the area to relieve itching inside the cast.
- C. The cast should be propped on at least 2 pillows when my child is lying down.
- D. I think I remember that standing cannot be done until after 72 hours.
Correct Answer: D
Rationale: The correct answer is D because there is no need to wait 72 hours before allowing the child to stand. The synthetic cast does not affect weight-bearing capacity, and standing can be done as tolerated. Choice A is incorrect because keeping the cast covered can lead to damage or accidents. Choice B is acceptable as applying an ice pack can help relieve itching. Choice C is also correct as elevating the cast on pillows can help reduce swelling and promote comfort during rest.
A client is receiving discharge instructions for using a walker. Which statement indicates an understanding of the teaching?
- A. I will hire someone to trim the tree that hangs low over the stairs of my front porch.
- B. I will avoid using the walker on uneven surfaces.
- C. I will use the walker on stairs for added support.
- D. I will not need to make any changes to my home environment.
Correct Answer: A
Rationale: The correct answer is A because hiring someone to trim low-hanging branches over stairs ensures home safety and reflects an understanding of walker use. This action indicates the client's awareness of potential hazards and the importance of a safe environment for walker use. Choice B is incorrect as avoiding uneven surfaces is a general safety precaution but does not directly relate to walker use and does not demonstrate an understanding of the teaching. Choice C is incorrect because using a walker on stairs is not recommended due to safety concerns such as balance and fall risks. Choice D is incorrect as making no changes to the home environment may pose safety risks when using a walker, showing a lack of understanding regarding safety precautions needed for walker use.
A client with a history of chronic obstructive pulmonary disease (COPD) is being discharged with home oxygen therapy. Which statement by the client indicates a need for further teaching?
- A. I will keep my oxygen tank upright at all times.
- B. I will not use petroleum jelly to keep my nose from drying out.
- C. I will not smoke or allow others to smoke around me.
- D. I will call my doctor if I have difficulty breathing.
Correct Answer: B
Rationale: The correct answer is B. Petroleum jelly is flammable and should not be used with oxygen therapy as it can increase the risk of fire. Using petroleum jelly near oxygen can lead to a fire hazard. Choices A, C, and D are correct statements that indicate proper understanding of oxygen therapy safety measures. Choice A emphasizes the importance of keeping the oxygen tank upright to prevent leaks, choice C highlights the necessity of avoiding smoking to prevent exacerbation of COPD, and choice D encourages seeking medical help promptly in case of breathing difficulties.
When is a depressed client at highest risk for attempting suicide?
- A. Immediately after admission, during one-to-one observation
- B. 7 to 14 days after initiation of antidepressant medication and psychotherapy
- C. Following an angry outburst with family
- D. When the client is removed from the security room
Correct Answer: B
Rationale: Depressed clients are at the highest risk of attempting suicide 7 to 14 days after starting antidepressant medication and psychotherapy. During this time, they may start to regain energy but still feel hopeless, which can increase the risk of suicidal ideation and behavior. Choices A, C, and D are incorrect because immediate post-admission, after an angry outburst with family, or when removed from a security room are not specific periods known to be associated with the highest risk of suicide in depressed clients.