Nokea
Which of the following nursing actions should the nurse TEACH the patient's care giver regarding tracheostomy care?
- A. Remove the tracheostomy tube if obstruction occurs
- B. Leave the tracheostomy ties in place until the physician change them
- C. Remove and clean the inner cannula daily
- D. Never put a covering over the tracheostomy stoma
Correct Answer: C
Rationale: Cleaning the inner cannula daily helps prevent the accumulation of secretions and debris, which can lead to blockages and infections. It is an essential aspect of tracheostomy care to maintain the patency of the airway and prevent complications. Caregivers should be taught how to safely remove, clean, and reinsert the inner cannula as part of routine tracheostomy care.
You may also like to solve these questions
A postpartum client who experienced a prolonged labor and instrumental delivery expresses concerns about breastfeeding difficulties. What nursing intervention should be prioritized to support successful breastfeeding in this situation?
- A. Providing education on techniques to facilitate milk let-down reflex
- B. Recommending supplemental formula feedings to ensure adequate nutrition
- C. Encouraging the client to consider exclusive formula feeding instead of breastfeeding
- D. Referring the client to a lactation consultant for specialized support
Correct Answer: D
Rationale: In the situation described, where the client experienced a prolonged labor and instrumental delivery, there may be physical and emotional factors impacting breastfeeding success. A lactation consultant is a specialized healthcare provider who can assess the client's breastfeeding difficulties, offer individualized support, and provide guidance on techniques to overcome challenges such as latch issues, positioning problems, and milk supply concerns. Referring the client to a lactation consultant will help ensure that she receives expert assistance tailored to her specific needs, thereby increasing the likelihood of successful breastfeeding. This proactive approach focuses on addressing the root causes of breastfeeding difficulties and supporting the client in achieving her breastfeeding goals.
Which is not a correct statement regarding record-keeping?
- A. Failure to do it could be evidence of professional liability
- B. It is an optional task to be done when circumstances allow.
- C. It is a tool in professional practice that helps provide quality care.
- D. It is part of the professional duty of the nurse.
Correct Answer: B
Rationale: Record-keeping is not an optional task; it is a critical aspect of professional nursing practice. As a nurse, maintaining accurate and timely records is essential for providing quality care, ensuring legal and ethical standards are met, and promoting patient safety. Failure to keep thorough records can lead to serious consequences such as compromising patient care, violating regulations, and even facing legal consequences. Thus, record-keeping should be seen as a mandatory part of the professional duty of nurses rather than an optional task that can be done when circumstances allow.
The blood protein involved in the immune system is:
- A. Thrombin
- B. Albumin
- C. Globulin
- D. Hemoglobin
Correct Answer: C
Rationale: Globulin is the blood protein involved in the immune system. There are different types of globulins, including immunoglobulins (antibodies) that play a crucial role in the body's defense against infections. These antibodies bind to foreign substances, such as bacteria and viruses, helping the immune system to recognize and destroy them. Thrombin is a clotting protein, albumin is a protein responsible for maintaining osmotic balance in the blood, and hemoglobin is a protein found in red blood cells that carries oxygen.
A patient with chronic kidney disease presents with progressively worsening anemia and elevated serum phosphate levels. Which medication is commonly prescribed to reduce serum phosphate levels in patients with chronic kidney disease?
- A. Epoetin alfa
- B. Cinacalcet
- C. Sevelamer
- D. Allopurinol
Correct Answer: C
Rationale: Sevelamer is a medication commonly prescribed to reduce serum phosphate levels in patients with chronic kidney disease. Sevelamer is a phosphate binder that works by binding to dietary phosphate in the gut, preventing its absorption into the bloodstream. By reducing serum phosphate levels, sevelamer helps manage complications associated with hyperphosphatemia in chronic kidney disease patients, such as mineral and bone disorders. Other medications like epoetin alfa are used to treat anemia commonly seen in chronic kidney disease patients, while cinacalcet is used to manage secondary hyperparathyroidism. Allopurinol, on the other hand, is used to treat gout by reducing uric acid levels and is not indicated for reducing serum phosphate levels in chronic kidney disease patients.
A patient is non-compliant with prescribed medications and treatment plans. What is the nurse's best approach to address non-compliance?
- A. Dismiss the patient's reasons for non-compliance and assert the importance of following the prescribed regimen.
- B. Listen actively to the patient's reasons for non-compliance, address any barriers or concerns, and collaborate on finding solutions.
- C. Ignore the patient's non-compliance and proceed with implementing the treatment plan regardless.
- D. Tell the patient that non-compliance is unacceptable and they must adhere to the prescribed regimen.
Correct Answer: B
Rationale: The nurse's best approach to address non-compliance with prescribed medications and treatment plans is to actively listen to the patient's reasons for non-compliance. By acknowledging and addressing any barriers or concerns the patient may have, the nurse can work collaboratively with the patient to find effective solutions. This approach promotes open communication, trust, and a patient-centered care plan that takes into consideration the patient's individual needs and circumstances. Dismissing the patient's reasons (choice A), ignoring the non-compliance (choice C), or resorting to a confrontational approach (choice D) are less effective strategies that may lead to further resistance and hinder the patient's willingness to engage in their treatment.