Nokea
Wilma, His sister and a nurse is suctioning the tracheostomy tube of James. Which of the following, if made by Wilma indicates that she is committing an error?
- A. Hyperventilating James with 100% oxygen before and after suctioning
- B. Instilling 3 to 5 ml normal saline to loosen up secretion
- C. Applying suction during catheter withdrawal
- D. Suction the client every hour
Correct Answer: A
Rationale: Suctioning a tracheostomy tube is a procedure that requires proper technique to prevent complications. Hyperventilating James with 100% oxygen before and after suctioning indicates that Wilma is committing an error. The correct approach is to provide pre-oxygenation with 100% oxygen for at least two minutes before suctioning to prevent hypoxemia. However, hyperventilation with 100% oxygen can lead to oxygen toxicity, which can be harmful to the patient. The other options, instilling normal saline to loosen secretions, applying suction during catheter withdrawal, and suctioning the client every hour are appropriate techniques when performing tracheostomy tube suctioning.
You may also like to solve these questions
A nurse prepares to administer a vitamin K injection to a newborn infant. The mother asks the nurse why her newborn infant needs the injection. The best response by the nurse would be:
- A. "You infant needs vitamin K to develop immunity."
- B. "The vitamin K will protect your infant from being jaundiced."
- C. "Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding."
- D. "Newborn infants have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel."
Correct Answer: C
Rationale: The correct response by the nurse is C. Newborn infants are born with low levels of vitamin K because they do not have enough of the gut bacteria necessary to produce it. Vitamin K plays a crucial role in blood clotting, and without enough of it, newborns are at risk of a bleeding disorder called vitamin K deficiency bleeding (VKDB). The vitamin K injection given to newborns helps prevent this disorder by providing them with the necessary vitamin K to ensure proper blood clotting. It is important for the mother to understand that this injection is essential for her infant's health and well-being to prevent complications related to vitamin K deficiency.
Rickets is caused by a deficiency in:
- A. vitamin A.
- B. vitamin C.
- C. vitamin D and calcium.
- D. folic acid and iron.
Correct Answer: C
Rationale: Rickets is a condition that primarily affects children and is characterized by softening and weakening of the bones, leading to skeletal deformities. This condition is caused by a deficiency in vitamin D and calcium. Vitamin D helps the body absorb calcium from the diet, and together they play a crucial role in bone health and development. Without enough vitamin D and calcium, the bones cannot mineralize properly, resulting in the characteristic symptoms of rickets. Other nutrients like vitamin A, vitamin C, folic acid, and iron do not directly cause rickets.
A nurse notes that a 12-hour-old newborn has not had the first meconium stool. The nurse documents this finding and continues to monitor the newborn because, in term newborns, the first meconium stool occurs within how many hours of birth?
- A. 6 to 8
- B. 8 to 12
- C. 12 to 24
- D. 24 to 48
Correct Answer: A
Rationale: In term newborns, the first meconium stool typically occurs within the first 6 to 8 hours after birth. Meconium is the baby's first stool, and its presence signifies that the baby's gastrointestinal system is functioning properly. If a newborn has not passed meconium within this timeframe, it may indicate an issue such as bowel obstruction that requires further evaluation and intervention. Therefore, the nurse should document and monitor the situation closely to ensure the newborn's health and well-being.
Mrs. Silang, a 52-year old female, is experiencing advanced hepatic cirrhosis now complicated by hepatic encephalopathy. She is confused, restless, and demonstrating asterixis. The nurse has formulated the nursing diagnosis: Altered thought processes related to which of the following?
- A. massive ascites formation
- B. fluid volume excess
- C. increased serum ammonia levels
- D. altered clotting mechanism
Correct Answer: C
Rationale: Hepatic encephalopathy is a neuropsychiatric complication of advanced liver disease, such as cirrhosis, where the liver's ability to metabolize ammonia is impaired. As a result, there is an increase in serum ammonia levels, leading to alterations in brain function and neurotransmission. Symptoms such as confusion, restlessness, and asterixis (flapping tremor) are characteristic of hepatic encephalopathy caused by increased ammonia levels affecting the brain. Therefore, altered thought processes in Mrs. Silang are primarily related to the increased serum ammonia levels rather than other factors like massive ascites formation, fluid volume excess, or altered clotting mechanism.
Which of the following symptoms most likely indicates that an infusion is infiltrated?
- A. Redness at the site
- B. Pain at the site
- C. Puffiness at the site
- D. Exudate at the site
Correct Answer: C
Rationale: Puffiness at the site is the symptom that most likely indicates that an infusion is infiltrated. Infiltration occurs when the IV fluid leaks into the surrounding tissues instead of entering the vein. This can lead to swelling and puffiness at the site as the fluid accumulates in the tissue. Redness, pain, and exudate at the site are also common signs of infiltration, but puffiness specifically points towards the fluid accumulating outside the vein. If infiltration is suspected, it is important to stop the infusion, remove the IV catheter, and apply appropriate treatment based on the severity of the infiltration.