Nokea
Which nursing action is most essential for the hospitalized client with a new tracheostomy?
- A. Decrease secretions
- B. Provide client teaching regarding tracheostomy care
- C. Relieve anxiety related to the tracheostomy
- D. Maintain a patent airway
Correct Answer: D
Rationale: Maintaining a patent airway is the most critical action for a client with a new tracheostomy to ensure adequate oxygenation. Other actions are important but secondary to airway patency.
You may also like to solve these questions
A client diagnosed with chronic kidney disease (CKD) has learned about managing diet and fluid restriction between dialysis treatments. The nurse determines that the client is compliant with the therapeutic regimen when the assessment demonstrates a weight gain of no more than how many kilograms between hemodialysis treatments?
- A. 0.5 to 0.9 kg
- B. 1 to 1.5 kg
- C. 2 to 4 kg
- D. 5 to 6 kg
Correct Answer: B
Rationale: The primary health care provider will prescribe the amount of fluid that the client is allowed to gain between dialysis treatments, but usually a limit of 1 to 1.5 kg of weight gain between dialysis treatments helps prevent hypotension that tends to occur during dialysis with the removal of larger fluid loads. The nurse determines that the client is compliant with fluid restriction if this weight gain is not exceeded.
A client with schizophrenia is responding well to risperidone (Risperdal) and is no longer psychotic. After teaching the client about managing his illness, which of the following statements reflects a need for further education?
- A. I just don't know if I can afford to keep taking medicines every day
- B. When my thoughts start racing, I know I need to relax more
- C. I can name the side effects of Risperdal, but I'm not having any
- D. I don't listen to my mom's religious beliefs about not using medicines
Correct Answer: A
Rationale: Concern about affording daily medication suggests a need for further education on resources or adherence strategies, as non-adherence risks relapse. Other statements reflect appropriate understanding.
The nurse is monitoring a client with a fracture to the left arm. Which sign observed by the nurse is consistent with impaired venous return in the area?
- A. Increasing edema
- B. Weakened distal pulse
- C. Pallor or blotchy cyanosis
- D. Continued pain despite medication
Correct Answer: A
Rationale: Impaired venous return is characterized by increasing edema. In the client with a fracture, this is most often prevented by elevating the limb. The other options identify signs of arterial damage, which can occur if the artery is contused, thrombosed, lacerated, or becomes spastic.
A client is admitted with a diagnosis of acute pancreatitis. The nurse should expect the client to report which of the following symptoms?
- A. Pain radiating to the right shoulder.
- B. Epigastric pain radiating to the back.
- C. Right lower quadrant pain.
- D. Diffuse lower abdominal pain.
Correct Answer: B
Rationale: Acute pancreatitis typically causes epigastric pain that radiates to the back due to pancreatic inflammation.
The nurse evaluates the arterial blood gas (ABG) results of a client who is receiving supplemental oxygen. Which Po2 finding would indicate that the oxygen level was adequate?
- A. 45 mm Hg
- B. 50 mm Hg
- C. 60 mm Hg
- D. 80 mm Hg
Correct Answer: D
Rationale: The normal Po2 level is 80 to 100 mm Hg. The remaining options are low values and do not indicate adequate oxygen levels.